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DIFFERENTIAL   DIAGNOSIS 


WITH 


CLINICAL   AIEMORANDA 


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INTRODUCTION  TO 

THE  OUTLINES  OF  THE  PRINCIPLES 

OF 

DIFFERENTIAL     DIAGNOSIS 

WITH 

CLINICAL  MEMORANDA 


BY 


Fred.  J.  SMITH,  M.A.,  M.D.  Oxon,  F.R.C.P.  Lond. 

PHYSICIAN   (with   care   OF   OUT-PATIENTS)   AND   SENIOR   PATHOLOGIST 
TO  THE  LONDON   HOSPITAL 


THE   MACMILLAN    COMPANY 

LONDON:   MACMILLAN  &  CO.,  Ltd. 
1899 

A^/  rights  reserved 


Copyright,  1899, 
By  the  MACMILLAN  COMPANY. 


Norfajooti  3prc8» 

J.  S.  Cushhig  &  Co.  —  Berwick  &  Smith 

Norwood  Mass.  U.S.A. 


PREFACE 

The  number  of  works  on  medicine,  and  its  various  quasi-special 
branches,  that  claim  the  time  and  attention  of  over -burdened 
students  and  practitioners  is  so  great  that  only  one  excuse  should 
be  offered  for  adding  to  it,  viz.  either  to  say  something  new  or  to 
put  forward  a  more  rational  and  simpler  arrangement  of  what  is  old. 
Very  little  that  is  new  will  be  found  in  the  following  pages,  but 
I  claim  that  I  have  attempted  to  arrange  the  old,  old  phenomena 
of  disease  in  such  a  manner  as  to  show  more  clearly  their  funda- 
mental meanings  and  relationships.  I  have  utiHsed  the  data  of 
physiology,  and  the  facts  of  pathological  anatomy,  as  the  source 
from  which  to  draw  inferences  and  deductions,  which  in  their  turn 
constitute  a  critical  analysis  of  clinical  symptoms ;  I  have  endeavoured 
by  this  analysis  to  lead  up  to  the  underlying  principles  which  govern 
disease  as  well  as  health.  Once  these  principles,  which  are  few  in 
number,  are  recognised,  bedside  symptoms  become  merely  illustra- 
tions of  them,  varied,  it  may  be,  by  local  and  individual  peculiari- 
ties, yet  ever  stamped  with  such  a  likeness  that  the  simplest 
induction  will  speedily  explain  the  organ  of  their  origin.  Isolated, 
or  apparently  isolated,  facts  thus  lose  their  isolation,  and  become 
members  of  a  related  community ;  they  no  longer  require  separate 
efforts  of  memory  for  their  retention,  but  fall  naturally  into  their 
places  as  deductions  from  a  universal  law. 


vi  DIFFERENTIAL  DIAGNOSIS 

I  thus  hope  that  what  I  have  written  will  serve  not  as  a  text- 
book of  medicine,  or,  indeed,  as  a  storehouse  of  facts,  but  as  a 
series  of  pegs  whereon  to  hang  a  chain  of  knowledge  which  will  be 
ever  increasing  link  by  link  as  experience  grows  more  ripe,  and  a 
larger  and  larger  number  of  varieties  of  symptoms  are  recognised  as 
varieties,  and  not  elevated  to  the  rank  of  species  by  ignorance  of 
the  connecting  links. 

Inasmuch  as  there  is  little  here  that  is  new,  I  have  mentioned 
very  few  authorities  for  the  clinical  points  I  have  utilised ;  they  are 
the  common  possession  of  the  medical  profession  at  large.  A  few 
original  ideas  of  my  own  are  scattered  throughout  the  work ;  time 
and  clinical  testing  alone  can  show  their  value,  but  they  are  at  least 
founded  on  some  considerable  experience,  and  the  method  of  their 
exposition  is  that  which  I  have  found  useful  in  teaching  by  the  bed- 
side. My  great  wish  has  been  to  be  as  accurate  as  possible,  so  as 
not  to  mislead  by  false  statements,  and  so  sin  by  commission ;  the 
omissions  are  only  too  glaring,  but  limitation  of  space  forbade 
further  inclusions. 

FRED.  J.  SMITH. 
138  Harley  Street,  W. 


CONTENTS 


CHAPTER    I 


PAGE 


Introduction — Definition  of  diagnosis  :  Steps  in  diagnosis — Antitoxin 
treatment — Causes  of  disease  :  Comments  on  the  various  classes  of 
causes — Processes  of  disease  :  Inflammation  ;  Degeneration  ;  New 
growths     ........  I 


CHAPTER    II 

Physical  signs  v.  symptoms — Pathology,  meanings  of — Contagion  v.  in- 
fection       .  .  .  .  .  .  ,  .21 


CHAPTER    HI 

Micro-organisms  and  disease — Reasons  for  believing  a  disease  to  be  due  to 
microbes — Differential  diagnosis  of  exanthems  :  General  explanation 
of  the  phenomena ;  Special  diagnostic  points — Varicella  v.  Variola 
— Variola  v,  syphilis — Diphtheria  v.  ulcerated  throat — Measles, 
rotheln,  and  scarlet  fever — Typhus  v.  typhoid — Cholera  v.  diarrhoea 
— Erythema — Influenza — Venereal  diseases  .  .  ,25 


CHAPTER    IV 

Diseases  of  thoracic  organs — Section   I.    Lungs   and   pleura — Pyrexia — 
Cough,  useless  and  useful — Sputum,  quantity,  quality — Respiration 


viii  DIFFERENTIAL  DIAGNOSIS 

PAGE 

— Dyspnoea  —  Pressure  effects — Pain  in  chest,  secondary  or  idio- 
pathic—  Physical  signs  —  Comparison  of  two  sides  :  Inspection  ; 
Palpation  ;  Percussion  ;  Auscultation  —  Laryngeal  affections  — 
Pneumothorax:  Cavities  —  Phthisis,  pneumonic,  fibroid,  haemor- 
rhagic,  miliary,  diagnosis  of —  Pneumonia,  incipient,  central ;  Is 
it  a  specific  disease  ? — Acute  bronchitis  and  bronchopneumonia — 
Chronic  bronchitis,  its  pulmonary  complications — Pleurisy,  causes 
of — Pleuritic  effusion — Intrathoracic  growths — Growth  v.  aneurysm  .  47 


CHAPTER    \N— Continued 

Section  II.  Heart  and  pericardium — Local  symptoms  and  physical  signs 
— General  symptoms  and  physical  signs — Heart  organs :  Hyper- 
trophy and  dilatation  ;  Compensation  and  failure ;  Diagnosis  of 
hypertrophy  and  dilatation,  of  compensation  and  failure — Endocardial 
V.  exocardial  sounds — Indications  and  meaning  of  bruits — Morbus 
cordis  without  bruits — Ulcerative  endocarditis  :  Its  pathology  and 
diagnosis:  Prognosis  in  heart  disease  .  .  .  .112 


CHAPTER   V 

Diseases  of  nose,  throat,  and  alimentary  system — Haemorrhage  :  From 
nose,  causes  ;  Issuing  by  mouth,  local  causes — Hsematemesis  v. 
haemoptysis :  Causes  of  haemoptysis  ;  Causes  of  haematemesis — 
Issuing  by  anus — Causes  of  melaena — Causes  of  haemorrhage  per 
anum — Vomiting  :  Causes — Colic  :  Diagnosis  of  causes  of ;  Treat- 
ment of — Colic  without  collapse  :  Differential  diagnosis  of  causes  of 
— Colic  V.  peritonitis — Differential  diagnosis  of  forms  of  calculus — 
Diarrhoea  and  constipation,  causes  and  diagnosis  of — Diarrhoea  in 
phthisis — Ascites,  primary  groups  of — Ascites  v.  encysted  fluid — 
Dyspepsia  v.  gastric  ulcer  .  .  .  .  .  .148 


CHAPTER   VI 

Diseases  of  the  urinary  organs — Normal  urine,  variations  in  health  ; 
Variations  in  disease,  frequency,  quantity,  colour,  specific  gravity, 
pathological  constituents,  tests  for  and  meaning  of — Albuminuria — 
Surgical  kidney — Pyuria,  causes  and  diagnosis  of — Haematuria, 
indications  of  locality  and  cause — Casts — Urates — Oxalates — Phos- 


CONTENTS  ix 

PAGE 

phates — Uric  acid,  consideration  of — Sugar,  consideration  of — 
Uraemia,  diagnosis  of — Suppression  v.  retention  :  Causes  of  suppres- 
sion and  retention — Bright's  disease,  varieties  of — Urine  in  consecu- 
tive nephritis — Stone,  tubercle,  and  carcinoma  of  kidney — Diabetes, 
phosphatic,  insipidus  .  .  .  .  .  .185 


CHAPTER    VII 

Affections  of  joints — Symptoms  of  joint  trouble — History  of  illness,  etc. 
— Charcot's  joints — Flat  foot — Gonorrhceal  rheumatism — Gonorrhoeal 
rheumatism  v.  simple — Traumatism — Hysteria — Synovitis — Tubercle 
— Rheumatism — Gout — Rheumatic  gout — Rheumatoid  arthritis — 
Differential  diagnosis  of  last  four  affections — Arthritic  diathesis  .        229 


CHAPTER    VIII 

Section  I.  Anatomy  and  physiology  of  the  nervous  system — The  neuron 
— The  peripheral  nerves — The  cord — Medulla — Brain — Functions  of 
the  same — Motor,  sensory,  and  reflex  tracts — Trophic  influences — 
Inco-ordination — Section  II.  Table  of  diseases  of  the  nervous  system 
— Section  IH.  Differential  diagnosis  of  nervous  diseases — Essential 
V.  secondary  ;  Organic  v.  functional  —  Peripheral  neuritis  —  Spinal 
cord,  systems  of,  indiscriminate  lesions  of — Cord  v.  peripheral  nerves 
— Medulla  and  pons,  tracts  and  cells  in — Mid-brain  hemiplegia — 
Cranial  nerves — Brain — Jacksonian  epilepsy — Traumatism — Organic 
lesion — Tumours  of  brain  .  .  .  .  .  .247 


CHAPTER    IX 

Urgency    cases — Haemorrhage — Other    vascular    lesions — Traumatism — 
Sudden  death — Lesions  of  nervous  system — Poisoning — Differential 
•   diagnosis    ........        326 


CHAPTER  I 

INTRODUCTORY    REMARKS    ON    DIAGNOSIS    IN    GENERAL 

Dr.  Pye  Smith  once  defined  pathology  very  pithily  as  "a  chat 
about  the  etiology  of  disease."  Though  I  think  the  definition  some- 
what too  narrow,  we  may  accept  it  provisionally  and  then  define 
diagnosis  as  "the  complete  analysis  of  etiology,"  for  we  cannot 
consider  a  diagnosis  as  absolutely  final  and  finished  until  we  have 
probed  etiology  to  the  bottom.  The  process  of  diagnosis,  thus 
scientifically  considered,  will  then  consist  of  three  stages  : — (i)  The 
collecting  of  as  complete  a  list  as  possible  of  the  immediate  pheno- 
mena of  disease  w^hich  are  universally  and  by  common  consent 
termed  symptoms  and  physical  signs,  e.g.  cough,  pain,  diarrhoea, 
paralysis,  palpitation,  etc.  (2)  Inferring  or  deducing  from  these 
collective  phenomena  a  primary  or  gross  diagnosis  as  to  the  organ 
or  organs  affected  and  the  general  nature  of  the  disease,  e.g.  bron- 
chitis, dyspepsia,  neuritis,  morbus  cordis,  etc.,  thus  arriving  at  what 
we  may  call  the  generic  title  of  the  affection.  (3)  A  final  step, 
viz.  the  identification  of  the  specific  cause  at  work,  thus  adding  a 
specific  name  to  the  generic  one,  e.g.  tubercular  bronchitis,  gouty 
dyspepsia,  septic  pneumonia,  rheumatic  arthritis. 

The  first  of  these  three  steps  is  naturally  the  simplest  proceed- 
ing, for  it  consists  only  in  taking  a  complete  history  of  the  case. 
Each  hospital  school  has  its  own  particular  method  of  case-taking, 
and  each  teacher  naturally  thinks  his  own  school  the  best,  and  I 
therefore  give  a  preference  to  the  following  card,  which  is  in  use  at 
the  London  Hospital.  It  has,  I  believe,  at  least  the  merit  of  not 
omitting  anything  of  importance  if  used  systematically. 
C     .  B 


DIFFERENTIAL  DIAGNOSIS  chap. 

Instructions  for  case-taking  in  Medical  Wards : — 

I,  The  Clinical  Clerk  to  enter  the  heads  of  the  case,  and  date  of 
the  Patient's  entry  to  Hospital,  and  fill  in  the  registered 
number  as  soon  as  possible.  Insert  dates  at  which  the  notes 
are  taken. 

II.  State  what  the  patient  complains  of — using  his  or  her  own  words 
verbatij7i  as  far  as  possible,  and  when  using  the  names  of  the 
days  of  the  week,  be  sure  to  insert  also  the  day  of  the  month. 

III.  Family  History — Number  and  condition  of  health  of  those 

living.     Ages  and  diseases  of  those  dead.      Note  any  family 

tendency  to  disease. 

This  section  is  especially  useful  for  the  following  diseases — 
rheumatism,  gout,  phthisis,  haemophilia,  nervous  diseases, 
asthma,  heart  disease ;  though  it  must  not  be  omitted  in 
any  case. 

Personal  History — Habits  (stating  quantity  and  kind  of 
alcohol  taken),  occupations,  residences,  previous  diseases 
and  illnesses,  noting  especially  the  dates  of  illnesses  or 
changes.  If  in  Hospital  before,  get  the  registered  number, 
and  insert  it  in  the  present  notes.  Especially,  never 
omit  to  inquire  for  any  disease  which  may  stand  in  etio- 
logical relationship  with  the  present  illness,  e.g.  rheumatism 
with  tonsillitis  or  morbus  cordis,  gout  and  lead  poisoning 
with  cirrhotic  kidney,  syphilis  with  many  conditions  ;  these 
three  diseases  should  never  be  omitted^  their  absence,  as 
well  as  presence,  being  equally  carefully  noted. 

Present  Illness — Date  and  manner  of  commencement :  order 
of  symptoms  and  dates  of  occurrence.  A  useful  question 
here  is — When  were  you  last  quite  well  ?  and  trace  the  ill- 
ness step  by  step  from  this. 

Probable  Cause — Insert  here  your  own  opinion  and  also  that 
of  your  patient,  and  any  higher  available  opinion. 

IV.  Present  Condition — General  condition.      This  should  never  be 

omitted  ;  the  most  important  items  are  perhaps — expression 
of  face,  colour  of  face  (anaemia,  cyanosis,  etc.),  oedema, 
nutrition,  distension  of  veins,  sleep,  easy  respiration,  etc.  ; 
note  position  of  patient  in  bed,  whether  sitting  up  or  lying 
down,  whether  restless  or  comfortable  and  quiet,  etc. 

V.  Digestion — Tongue,  teeth,  throat,  appetite,  vomiting,  hasmate- 
mesis,  bowels. 

Syinptoms — Fulness  or  pain  after  food,  flatulence,  colic  or 
other  disturbance.     Abdominal  pain  or  tenderness. 


I  DIAGNOSIS  IN  GENERAL  3 

Liver — Size  and  character  as  determined  on  percussion  and 
palpation.     Whether  tender  or  not.      Jaundice. 

Spleen — Percussion,  palpation. 

Abdomen — Its  physical  condition  as  indicated  by  palpation, 
percussion  and  mensuration.  Distension,  retraction. 
Ascites.     Tumour,     Abdominal  pain. 

VI.   Vascular  System — Pulse  frequency  and  characters,  condition  of 
arteries,  veins,  capillaries.     Heart  palpate,  percuss,  auscultate. 

Syvipto77is — Palpitation,  pr£ecordial  dulness,  pain,  etc. 

VII.   Respiratory  System — Dyspnoea,  frequency,  characters  of  respir- 
atoiy  movements,     Cough,  expectoration,  hsemoptysis. 

Physical  examination^  inspection,  palpation,  percussion,  auscul- 
tation, condition  of  larynx. 

VIII,  Nervous  System — Geiieral  condition.  Intelligence,  mental 
state,  sleep,  speech.  Vertigo,  delirium,  coma.  Complaints 
of  head  pain,  vomiting,  numbness,  neuralgia.  Paralysis, 
convulsions,  spasms,  tremor. 

Motor  power — Limbs,  trunk,  action  of  sphincters.  Ability  to 
walk  and  do  ordinary  work.  Power  over  large  joints, 
small  joints,  finer  movements  of  fingers,  e.g.  writing. 

Cranial  nerz'es — Movements  of  eyes,  tongue,  face,  palate. 
State  of  pupils. 

Special  senses — Ophthalmoscopic  appearances.  This  should 
never  be  omitted,  but  is  more  especially  important  in  (i) 
anaemia,  (2)  Bright's  disease,  (3)  cerebral  and  spinal 
diseases,  (4)  syphilis,  (5)  any  disease  in  which  amblyopia  is 
complained  of. 

Sensibility — Tactile  sensibility  of  skin,  anaesthesia,  hyper- 
assthesia,  dyssesthesia  (perverted  sensations,  e.g.  numbness, 
burning  pain,  etc.).      Sensibility  to  heat  and  cold. 

Reflexes — Superficial  and  deep.  Patellar,  plantar,  wrist,  ab- 
dominal, cremasteric,  etc. 

In  Spinal  Cases.,  gait  in  walking,  power  in  each  limb,  condition 
of  sphincters. 

In  any  nervous  case  the  special  points  to  be  attended  to 
without  exception  in  any  case  are  (i)  hereditary,  (2)  manner 
and  time  of  onset,  (3)  condition  of  reflexes,  (4)  static  and 
locomotor  equilibration. 


4  DIFFERENTIAL  DIAGNOSIS  chap. 

IX.  Locomotor  System — State  of  bones,  muscles,  joints,  scars, 
nodes.     Skin^  moist  or  dry.      Bed  sores. 

X.   Lymphatic  Glands — Neck,  groins,  axilla.      Size,  mobility,  sup- 
puration. 

XI.  Urine — Frequency  of  micturition.  Quantity,  colour,  reaction, 
specific  gravity.  Albumen.  Sugar.  Deposit.  Microscopical 
and  chemical  characters  of  deposit. 

XII.  Generative  System — Menstruation,  frequency,  duration,  quan- 
tity in  excess  or  otherwise,  whether  painful,  other  discharges. 
Conditions  of  uterus  and  pelvic  organs  (when  examination  is 
possible). 

XIII.  Treatment — Prescriptions  and  diet  to  be  entered,  and  all  alter- 

ations noted  with  dates. 

XIV.  Progress  of  Case  to  be  noted  as  occasions  may  require.      Pulse 

should  be  recorded  whenever  the  temperature  is  taken.     Urine 
must  be  noted  at  least  once  a  week. 

When  important  symptoms  or  complications  occur,  besides  a 
description  in  the  text,  an  indication  should  be  given  in  the 
margin.  As  a  good  general  hint  for  note  making,  remember 
m  all  cases^  without  exception^  a  note  should  be  made  on 
the  first  day  after  admission  ;  in  all  acute  cases  a  note 
should  be  made  every  day  while  the  symptoms  persist;  after 
this,  notes  may  be  made  less  frequently,  but  any  fresh  symp- 
tom or  complication  must  be  immediately  noted. 

XV.  Result — A  description  of  the  patient  at  the  time  of  discharge, 
or  the  mode  of  death,  should  be  given  at  the  termination  of  the 
case.  This  is,  in  some  respects,  the  most  important  part  of  a 
Clerk's  duty,  and  must  on  no  account  ever  be  ojnitted  in  any 
case.  The  description  need  only  be  of  that  system  or  systems 
which  have  been  affected  by  the  disease. 

The  Clinical  Clerk  to  sign  his  name  in  full  on  completion  of 
the  case. 

At  the  second  step  diagnosis  frequently  stops  short ;  possibly, 
though  let  us  hope  rarely,  from  carelessness  or  indifference  on  the 
part  of  the  observer,  as  when  a  cough  or  diarrhoea  is  treated  by  a 
dose  of  opium  (reluctance  on  the  part  of  the  patient  to  submit 
himself  to  thorough  examination  has  sometimes  too  to  be  over- 
come) ;  more  frequently  and  excusably  because  further  information 
is  useless  in  the  present  state  of  our  therapeutical  knowledge,  or 
because  some  very  obtrusive  symptom  must  be  immediately  subdued 


I  DIAGNOSIS   IN    GENERAL  5 

if  the  patient's  life  is  to  be  saved  even  temporarily,  as  may  happen 
in  hyperpyrexia  from  any  cause,  or  in  the  agony  of  calculous  colic ; 
most  frequently  and  really  unavoidably  because  the  further  informa- 
tion required  is  absolutely  unattainable  until  death  has  afforded  the 
opportunity  for  more  thorough  investigation,  as  in  a  case  of  severe 
haemoptysis,  for  example,  or  rapidly  fatal  septic  pneumonia  or  per- 
forative peritonitis.  Like  the  first  step,  this  second  one  is  in  many 
cases  a  very  simple  matter,  but  to  the  student  and  young  prac- 
titioners it  is  apt  to  appear  easier  than  it  really  is.  Nothing  but 
wide  experience  by  the  bedside  and,  above  all,  in  the  post-mortem 
room,  will  convince  us  of  the  difficulties  which  surround  even  the 
simplest  accurate  diagnosis,  and  there  can  be  no  greater  mistake 
than  that  of  at  once  accepting  the  most  obvious  as  the  most  correct. 
Apart  from  the  above  exceptions  and  difficulties,  it  should  ahvnys 
be  our  endeavour  to  take  the  third  and  final  step  in  diagnosis.  Of 
its  importance  generally  in  clinical  medicine  examples  are  almost 
superfluous,  the  point  is  so  universally  admitted.  I  need  only 
mention  the  flood  of  light  thrown  on  an  obscure  case  of  albuminuria 
by  the  recollection  of  a  forgotten  attack  of —  it  may  be  mild  —  scarlet 
fever,  what  a  relief  to  our  anxieties  it  is  to  find  a  bad  sore  throat  as 
a  precedent  fact  in  a  case  of  squint,  and,  per  contra,  how  the  dis- 
covery of  the  bacillus  tuberculosis  in  the  sputum  redoubles  our 
anxieties  about  what  was  previously  looked  upon  as  a  simple 
catarrh.  But  beyond  all  this  the  discoveries  of  the  last  quarter  of 
a  century  in  bacteriology  have  made  this  third  step  of  much  greater 
importance  still,  for  they  have  held  out  to  us  hopes  of  cure  in  many 
cases  hitherto  incurable.  Whether  these  hopes  are  destined  in  the 
future  to  be  realised  or  disappointed  it  would  be  rash  to  prophesy, 
though  certainly  the  results  hitherto  obtained  are  encouraging. 
As  the  basis  on  which  these  hopes  are  founded  is  very  germane  to 
the  completion  of  a  diagnosis,  we  may  here  enunciate  its  principal 
points.     Stated  in  order  the  argumentative  propositions  run  thus  :  — 

(i)  Many   groups    of    symptoms    or    diseases    are    caused   by 
microbes  invading  the  body. 

(2)  In  many  of   these,  if  not  in  all,  the    actual  symptoms  are 

caused  by  a  toxin  or  toxins  manufactured  by  the 
microbes,  either  directly  from  their  own  metabolism  or 
indirectly  from  the  tissues  of  the  victim. 

(3)  The  spontaneous  cure  of  such  symptoms  is,  at  least  in  some 

cases  (possibly  or  probably  in  all),  effected  by  an  anti- 
toxin or  neutraHser  of  the  previous   toxin;  this  in  turn 


6  DIFFERENTIAL   DIAGNOSIS  chap. 

may  apparently  be  produced  either  by  the  microbes  or 
the  tissues. 

(4)  Such  antitoxin  can  be  obtained,  with  more  or  less  success 

(by  methods  which  need  not  here  be  entered  upon),  in 
quantities  and  condition  available  for  therapeutic  uses. 

(5)  It  should  follow,  and  has  in  many  cases  already  been  proved  to 

follow,  that  the  injection  of  such  antitoxin,  if  effected  early 
enough  in  the  disease,  is  efficacious  in  curing  the  patient. 

These  propositions  would  appear  to  be  scientifically  demon- 
strated, but  there  is  one  point  which  is  still  in  doubt,  and  that  the 
most  important  one  from  our  present  point  of  view;  it  is  this  — 
does  each  separate  and  identifiable  microbe  produce  a  special  and 
specific  toxin,  i.e.  a  poison  of  definite  composition  —  as  definite,  say, 
as  morphine  or  other  alkaloid  —  peculiar  to  itself  and  requiring  for 
its  neutralisation  an  equally  definite  and  specific  antitoxin?  or,  on 
the  other  hand,  do  many  diiferent  microbes  produce  a  common 
toxin,  so  that  the  antitoxin  produced  by  one  microbe  or  method  of 
preparation  can  be  used  for  the  toxin  of  another  kind  of  microbe? 
All  the  evidence  —  at  least  the  weight  of  evidence  —  we  at  present 
possess  points  in  the  direction  of  the  former  of  these  two  supposi- 
tions being  the  true  one.  Witness  the  almost  conclusive  clinical 
experience  in  the  treatment  of  diphtheria,  of  rabies,  and  of  tetanus, 
as  well  as  the  brilliant  successes  and  the  disappointing  failures  in 
cases  of  septic  disease,  in  which  the  particular  microbe  at  work  is 
less  definite  or  less  famihar,  and  where  success  has  been  com- 
pulsorily  attributed  to  the  right  antitoxin,  failure  being  due  either 
to  the  wrong  antitoxin  or  to  a  too  late  application.  I  think,  there- 
fore, we  shall  be  obliged  ultimately  to  admit  its  truth,  and  we  can 
see  at  once  on  this  admission  how  enormous  is  the  importance  of 
the  third  step  in  diagnosis,  to  be  able  to  say,  "  This  case  of  illness 
is  due  to  this  particular  microbe,  and  I  must  use  its  antitoxin  as 
quickly  as  possible." 

Besides  this  therapeutical  use  of  a  completed  diagnosis,  the 
principle  of  toxins  and  antitoxins  has  lately  been  applied  to  that 
completion  itself,  vide  Typhoid  Fever.  May  we  not  hope  in  the 
future  to  see  the  two  procedures  more  frequently  working  hand 
in  hand,  complementary  to  one  another? 

Causes  of  Disease  in  General 

In  the  special  sections  of  this  work  we  shall  always  be  consider- 
ing diagnosis  as  an  induction  from  symptoms.     We  may  here  in  the. 


I  DIAGNOSIS  IN  GENERAL  7 

introductory  or  general  chapter  briefly  review  the  matter  from  the 
other  standpoint,  and  see  what  are  the  causes  of  disease  and  the 
general  processes  by  which  these  causes  produce  the  symptoms 
which  we  have  later  to  analyse. 

The  fundamental  causes  of  disease  belong  to  but  few  really 
separate  categories,  which  may  be  presented  in  comprehensive 
forms  as  follows  : — 

Causes  of  Disease 


A.   From  without  (environment  in  the  larger  sense)  : — 


O 


•5   <^ 

O  ^ 


to 
c 

'6 
o 
U 


r  Chemical  (on  the  surface  of  the  body). 
Traumatism  \  Grossly  physical  eftects,  and  those  of  excess  of  heat 
I      and  cold. 

.     ,  .    I  External  —  fleas,      lice, 

Alacroscopical  or  coarselv  I       , 

•^    .  '  -       bug's,  etc. 

microscopic  .  •  K   .         1 

^  1^ Internal — worms,  etc. 

(i)  Essentially  patho- 
genic, or  (2)  rend- 
ered so  by  peculiar 


Parasitic 


Poisons 


flj   2  c  c 

£  ^  c  2 

o    3  °    ^ 

.      a  rt    rt 

.£  •-  c  ^ 


Finely    microscopic    (mi- 


crobes) 


(opportunities  ofvital- 
ity  or  food  supply. 

arsenic,      alkaloids,     pto- 


^  Recognised  as  such 
maines,  etc. 
Ordinary  articles  of  food  rendered  injurious  by 
circumstances  of  too  free  indulgence,  imperfect 
mastication,  decomposition,  etc.,  and  also  by 
unusual  changes  in  digestion  with  absorption  of 
poisonous  ptomaines,  etc. 

/Perforation  of  a  hollow  tube  from  any  cause  what- 
ever. 

Direct  extension  of  processes  of  disease  from  one 
organ  to  another. 

Carried  in  the  blood  or  lymph  stream,  convected 
from  place  to  place. 

Forced  malpositions,  as  twisting  of  tubes  and  dis- 
locations of  more  solid  organs. 


B    From  within  (idiopathic,  so  to  speak) 


{a)  The  more  or  less  direct  effect  of  altered  function  in 
one  organ   upon    another   organ,    e.g.   the   inter- 


8  DIFFERENTIAL  DIAGNOSIS  chap. 

related    functions     of     liver,     stomach,     kidney, 

pancreas,  etc. 
b)  The  effects  of  wear  and  tear,  age  in  its  physiological 

sense. 
{c)    Congenital    or    inherent   debility    of  tissue    either 

absolute  or  relative  to  the  work  demanded  of  it. 
{d)  New  growths  of  intrinsic  formation. 

That  the  apparently  innumerable  causes  of  disease  should  be 
reducible  to  such  a  small  number  of  independent  types  is  at  first 
somewhat  startling,  but  I  think  a  little  consideration  and  comment 
will  show  that  the  above  errs  on  the  side  of  excess  rather  than 
defect,  and  that  some  of  the  groups  overlap. 

Traumatism. — In  its  widest  sense — of  injury — this  would  in- 
clude nearly  all  the  other  causes  of  ill  health  which  arise  from  the 
environment  of  the  individual.  Food  imperfectly  masticated  or 
otherwise  by  its  physical  qualities  unsuitable  for  digestion  is,  for 
example,  very  likely  to  cause  a  wound  of  the  stomach  with  its 
attendant  evil  consequences.  In  its  grosser  sense  the  cause  belongs 
almost  entirely  to  surgery.  We  may  recognise  its  probable  single 
action  when  health  speedily  returns  after  the  removal  of  an  exciting 
causa  causans.  Mr.  Hutchinson  would  refer  most  skin  diseases  to 
this  category  or  the  next. 

Parasites. — Of  the  grosser  forms  of  external  parasites  the  action 
is  mildly  irritative  or  traumatic,  increased  largely  by  scratching  or 
rubbing.  If  through  the  wounds  thus  produced  microbes  find  an 
entry  to  the  blood  or  lymphatic  vessels — the  skin  teams  with  ever 
watchful  enemies  of  this  character — the  result  may  be  as  bad  as, 
in  fact  is  identical  with,  the  other  microparasitic  troubles,  the  skin, 
instead  of  some  mucous  or  other  surface,  being  the  point  of 
entry  which  is  thus  more  easily  traceable.  Of  the  larger  internal 
parasites — collectively  denominated  worms — the  results  are  more 
varied.  Thus  round  and  tape  worms  may  reside  within  us  without 
causing  any  trouble  whatever,  but  they  may  cause  much  irritation 
with  reflex  symptoms,  they  may  block  passages,  e.g.  the  common 
or  cystic  bile  duct,  or  cause  tumours  (hydatids),  or  by  migration  of 
the  young  {Trichina  spiralis^  cause  serious  symptoms  in  any  organ ; 
the  Anchylostoma  duodenale  may  produce  profound  anaemia  by 
abstraction  of  blood. 

To  the  second^finely  microscopic — group  of  parasites  the  ever- 
multiplying  discoveries  of  medical  science  are  rapidly  relegating 
every  disease  to  which  human  flesh  is  heir.     Possibly  enthusiasm 


I  DIAGNOSIS   IN    GENERAL  9 

rather  than  hard  facts  is  having  something  to  say  in  this  matter. 
When  present  in  numbers,  or  with  virulence  sufficient  to  create  a 
pathological  disturbance  in  the  body,  they  have  one  almost  invari- 
able and  common  result,  viz.  pyrexia  (in  primary  syphilis,  in  gonor- 
rhoea, and  possibly  a  few  others  —  chronic  rheumatoid  arthritis,  for 
example  —  this  is  least  marked,  and  even  in  tubercle  it  is  doubtful 
how  much  of  the  fever  is  due  to  the  specific  bacillus),  a  result  to 
be  expected  when  we  consider  the  enormously  preponderating  influ- 
ence which  metabolism  has  in  the  production  of  our  supply  of  body 
heat,  and  then  remember  that  in  microbic  disease  either  a  toxin  or 
a  contagium  vivum  is,  or  may  be,  carried  all  over  the  body,  stimu- 
lating every  part  of  it  to  a  metabolic  antagonism.-^  This  pyrexia 
itself,  however,  almost  immediately  offers  points  of  difference  aiding 
diagnosis,  in  suddenness  of  onset  and  rise,  in  duration,  in  irregular 
variability  or  regular  periodicity;  cf.  typhoid  and  typhus,  scarlet 
fever  and  measles,  malaria  and  general  septicaemia,  etc.  In  many 
cases,  too,  the  seat  of  inoculation  or  of  first  morbid  appearances  is 
available,  the  uterus  in  the  puerperium,  the  tonsil  in  diphtheria,  the 
genito-urinary  apparatus  in  venereal  diseases.  Still  later  we  have 
the  selective  seat  in  which  the  poison  has  left  its  traces,  such  as  the 
peripheral  nerves  in  diphtheria,  the  kidneys  in  scarlet  fever,  the  spleen 
in  malaria,  etc.  Further  points  will  be  found  in  the  special  sections. 
Poisons.  —  Poisons,  as  ordinarily  understood,  may  be  divided 
into  three  classes  :  (i)  Those  which  act  upon  the  alimentary  canal, 
and  are  practically  not  absorbed,  e.g.  all  corrosives  and  many 
irritants;  (2)  those  which  only  act  after  absorption,  e.g.  most  alka- 
loids; (3)  those  which  act  in  both  ways  typically,  phosphorus, 
arsenic,  and  oxalic  acid.  The  first  and  last  classes  will  show  ali- 
mentary symptoms  in  excess,  vomiting  and  diarrhoea  within  a  short 
time  of  being  taken,  and  have  one  point  in  common,  in  marked 
contrast  to  the  common  symptom  in  microbic  invasion :  this  is 
a  subnormal  temperature,  largely  induced  by  shock  and  mental 
anxiety.  The  second  class  in  its  entirety,  and  the  third  in  the 
later  phases  of  a  case,  show  appropriate  features  according  to  the 
selective  affinity  of  the  poison  for  special  organs,  digitahs  for  the 
heart,  conium  and  strychnine  for  the  motor  nerves,  phosphorus 
for  liver  and  muscles,  opium  and  belladonna  for  the  cerebral  cortex, 
etc.,  and  thus  the  case  may  be  provisionally  or  even  finally  diagnosed 
in  conjunction  with  the  history. 

1  This  metabolic  activity  or  antagonism  not  only  explains  the  phenomenon  of 
pyrexia,  but  also  lies  very  close  to  the  root  of  ^vhat  ivide  Processes  of  Disease)  we 
know  as  inflammation. 


lo  DIFFERENTIAL   DIAGNOSIS  chap. 

When  articles  of  diet  become  injurious,  they  too,  like  the  more 
virulent  poisons,  produce  symptoms  in  one  of  two  ways:  (i)  by 
acting  as  immediate  irritants  to  the  alimentary  canal,  with  vomiting 
and  purging,  as  in  ptomaine  poisoning,  or  in  actual  surfeit  of  food 
otherwise  wholesome;  (2)  by  pouring  into  the  blood  or  lymph 
stream  a  greater  supply  of  nutriment  than  can  be  adequately 
disposed  of  in  the  great  chemical  laboratories  of  the  body ;  hence 
arise,  more  immediately,  unpleasant  sensations  in  the  shape  of 
sleepiness,  biliousness,  headache,  etc.,  and  remotely,  a  storing  up 
of  an  undue  amount  of  fat  —  obesity  —  flabbiness  of  body  and  mind, 
general  lassitude,  etc.,  and  perhaps  more  remotely  still,  gout  and 
goutiness,  with  all  their  pains  and  penalties,  and  possibly  also  a 
lessened  resistance  to  attacks  of  microbic  troubles. 

Immediate  Surroundings.  —  From  the  little  world  of  its  own 
special  environment  every  internal  organ,  which  has  no  immediate 
and  direct  communication  with  the  larger  external  world,  gets  all 
its  serious  troubles.  The  blood  and  lymph  that  bathe  its  tissues 
bring  with  them  the  chemical  or  vital  poisons  that  interfere  with  its 
physiology,  or  cause  grosser  mischief  still,  e.g.  nephritis,  acute 
yellow  atrophy,  meningitis,  endocarditis,  etc. ;  the  perforation  of  a 
tube  allows  its  contents  to  become  a  serious  source  of  irritation  to 
neighbouring  structures  —  gangrenous  inflammation  from  extra- 
vasation of  urine,  for  instance,  when  ureter,  bladder,  or  urethra  is 
ruptured,  or  peritonitis  when  the  contents  of  the  alimentary  canal 
are  allowed  to  escape  freely  into  the  peritoneal  cavity.  Inflamma- 
tion has  but  slight  respect  for  the  fascial  or  fibrous  boundaries 
laid  down  for  its  guidance  by  anatomists,  but  spreads  with  but  Httle 
hesitation  from  meninges  to  brain  or  cord,  from  endo-  or  peri- 
cardium to  myocardium,  from  stomach  to  liver,  etc.  Displacements 
of  the  heart  by  pleural  effusions  or  more  solid  growths  will  cause 
serious  interference  with  the  circulation ;  a  displaced  kidney  brings 
about  a  great  deal  more  than  simple  mental  worry ;  twisting  of  the 
gut,  or  even  of  a  pedicelled  tumour,  may,  and  often  does,  bring  about 
a  fatal  illness.  All  these  are  illustrations  of  the  working  of  the 
internal  environment,  and  yet  there  are  but  few  of  them  which 
with  equal  propriety  might  not  be  put  under  the  heading  primarily 
of  poisons  or  traumatism. 

Arising  from  within  —  Idiopathic  Diseases.  —  It  is  only  by 
courtesy  —  because  we  cannot  always  discover  the  original  culprit  — 
that  disease  in  one  organ,  almost  certainly  arising  from  the  wrong- 
doing of  another,  can  be  called  idiopathic,  or  that  this  group  can 
retain  its  position  amongst  the  primary  causes  of  disease.     We  often 


I  DIAGNOSIS  IN  GENERAL  ii 

speak  of  a  primary  congestion  of  the  liver,  or  of  an  idiopathic 
anemia,  but  in  both  cases  it  is  extremely  probable  that  the  ali- 
mentary canal  is  the  first  offender  by  passing  an  excess  of  suitable, 
or  some  unsuitable,  material  to  the  liver  or  blood,  which  in  turn 
exhibit  the  symptoms  of  complaint ;  and  even  now  we  have  to  throw 
the  blame  rather  on  the  individual,  who  has  by  over-feeding  or 
neglect  of  defecation  originally  induced  a  plethora  of  nutrient 
material  or  absorption  of  poisonous  products  of  food  decomposition 
unavailable  for  nutritive  purposes.  In  pneumonia  and  bronchitis 
danger  but  rarely  arises  from  obvious  asphyxia  ;  it  is  almost  constantly 
due  to  the  difficulties  the  heart  experiences  in  keeping  up  the  circula- 
tion. This  in  turn  may  be  due  to  the  imperfect  oxygenation  of  the 
blood  by  the  lungs.  Still  the  lung  trouble  is  originally  derived  from 
without.  When  the  functions  of  the  kidney  are  imperfectly  per- 
formed every  organ  in  the  body  feels  it,  owing  to  imperfect  removal 
of  waste ;  yet  the  kidney  itself  has  suffered  for  the  fault  of 
stomach,  or  from  the  introduction  of  microbic  toxins.  In  fact,  the 
more  we  inquire  into  this  group  of  causes,  the  less  the  reason  for 
retaining  it,  and  the  more  does  it  divide  itself  up  amongst  the  other 
groups. 

Wear  and  Tear. — In  wear  and  tear  we  get  the  first  trace  of 
disease  really  independent  of  external  conditions ;  they  are  the 
essential  conditions  under  which  all  living  things  exist.  It  is  a 
common  idea  with  the  laity  that  in  seven  years  every  cell  of  the 
body  is  changed  in  its  constituent  molecules.  As  far  as  I  know, 
there  can  be  no  exact  foundation  for  this  belief,  but  it  probably, 
for  all  that,  contains  a  pregnant  approximation  to  the  truth,  and 
should  loss — however  gradual — be  not  equalled  by  repair  and  re- 
placement, function  must  suffer,  with  the  inevitable  reaction  known 
as  dis-ease.  The  deficit  in  childhood  is  evidently  nil,  and  as  age 
advances,  with  waning  elasticity  in  power  of  repair,  it  may  be 
extremely  minute,  so  that  many  years  may  elapse  before  the 
resultant  loss  of  function  is  sufficient  to  attract  attention.  I  think 
it  probable  that  many  cases  of  so-called  cirrhotic  kidney — and  a 
better  illustration  of  a  chronic  insidious  disease  could  not  be  given 
— are  thus  induced.  The  kidney  mischief — want  of  repair  in 
epithelial  cells — acts  and  reacts  in  turn  upon  the  vascular  system, 
where  indeed,  in  the  shape  of  arterio-capillary  fibrosis  and  atheroma, 
the  effects  of  age  are  more  visible  and  pronounced,  and  also  more 
serious  than  in  any  other  organ  or  tissue.  This  vascular  degenera- 
tion operates  in  two  ways:  (i)  directly,  the  vessels  themselves 
becoming  brittle  and  absolute  rupture  taking  place,  or  by  losing 


12  DIFFERENTIAL  DIAGNOSIS  chap. 

natural  elasticity  ^  they  gradually  yield  to  the  blood  pressure  within 
them,  and  aneurysms,  large  or  small,  single  or  multiple,  form,  with 
all  their  attendant  dangers;  (2)  indirectly;  the  minuter  vessels  by 
their  pathological  changes  either  (thrombosis)  starve  outright  the 
tissues  to  which  they  are  distributed,  or  (by  thickening  and  altera- 
tion of  wall)  interfere  with  that  due  interchange  of  nutrient  and 
waste  material  which  is  the  life  of  the  tissues,  and  thus  lead  to 
such  impaired  vitality  that  the  tissues  cannot  adequately  resist 
untoward  influences  —  toxins,  etc,  —  nor  properly  repair  damage 
inflicted  upon  them.  It  is  by  such  considerations  as  these  that 
we  are  led  easily  to  understand  how  in  old  people  or  those  prema- 
turely worn  out  (alcoholic  excesses,  physical  toil,  chronic  lack  of 
nourishing  food)  the  prognosis  of  disease  is  made  much  worse, 
and  also  to  appreciate  why  symptoms  in  such  patients  may  be 
unexpectedly  obscure  or  insidiously  vague ;  pyrexia,  that  constant 
accompaniment  of  metabolic  resistance  and  cell  warfare,  may  be 
but  slight,  or  even  absent  in  cases  which  would  otherwise  be  termed 
acute ;  the  foundations  of  life  may  be  sapped  and  death  intervene 
while  we  are  still  waiting  for  the  explosion  of  general  and  local 
manifestations  that  should  tell  us  where  the  enemy  is  attacking; 
a  smouldering  pneumonia,  an  apyrexial  empyema,  a  chronic  and 
insidious  uraemia  will  illustrate  the  point. 

Congenital  or  Inherent  Debility  of  Tissue. — Considered  strictly, 
this  whole  group  can  only  be  a  particular  illustration  of  the  influence 
of  the  immediate  environment,  of  the  physiological — or  pathological 
rather — influence  of  one  organ  upon  another,  for  during  intra- 
uterine life  the  foetus  is  as  much  a  part  of  the  mother  as  her  kidneys 
or  heart,  and  is  as  much  dependent  for  its  health  and  integrity 
upon  the  due  interrelation  of  her  organs  as  are  those  organs  them- 
selves dependent  upon  one  another.  For  more  practical  or  clinical 
purposes,  however,  the  matter  assumes  a  different  aspect,  and  we 
may  divide  these  into  three  fairly  distinct  categories.  First,  those 
cases  in  which  an  active  process  of  disease  is  going  on  in  the  child 
at  the  time  of  birth,  a  disease  which  has  actually  attacked  it — been 
transmitted  to  it  conveys  a  slightly  different  impression — while  it 
was  part  of  the  mother.  Syphilis  and  the  acute  specific  fevers  offer 
us  typical  examples  of  this,  and  recent  reports  would  seem  to 
render  it  possible,  if  not  probable,  that  tubercle  may  in  a  similar 
way  attack  a  child  in  utero.     Simple  anatomical  deformities  might 

^  It  must  be  remembered  that  elasticity  essentially  consists  in  a  "  power  to  return 
to  an  original  form  after  a  distorting  force  of  any  kind — pull,  pressure,  or  twist — has 
ceased  to  act." 


I  DIAGNOSIS  IN  GENERAL  13 

be  placed  in  the  same  class.  Secondly,  those  cases  in  which 
inherent  defect  of  tissue  is  assumed — rather  than  proved — to  exist 
to  explain  certain  so-called  idiopathic  affections.  A  child,  for 
instance,  is  born  healthy  to  all  appearance,  and  remains  so  for  years, 
and  yet  without  any  ascertainable  cause  disease  makes  its  appear- 
ance in  certain  structures  or  organs ;  mental  deficiencies,  primary 
sclerosis  of  parts  of  the  nervous  system,  primary  myopathies,  haemo- 
philia, would  be  examples  of  this  class,  amongst  many  others,  in 
which  we  invoke  heredity  as  a  deus  ex  machina.  Thirdly,  the  prin- 
ciple may  with  a  little  extension  be  used  to  explain  those  delightful 
words,  "  idiosyncrasy,"  "  dyscrasia,"  "  diathesis,"  etc.,  which  are  such 
beautifully  simple  ways  of  explaining  (! !)  our  ignorance  of  etiology. 
Thus,  a  number  of  people  take  a  similar  dose  of  a  drug;  some 
exhibit  marked  effects,  others  none.  Why  ?  Oh,  idiosyncrasy ! 
Again,  a  dozen  individuals  are  exposed  to  the  same  unusual  dis- 
turbance of  gross  environment ;  one  gets  acute  rheumatism,  another 
nephritis,  another  pneumonia,  another  pleurisy,  another  chorea, 
and  some  show  no  trace  of  the  storm.  Why?  Oh,  different 
diatheses  is  the  glib  reply.  However,  explain  or  mystify  the  matter 
as  we  may,  the  facts  remain,  and  we  utilise  them  clinically  when  we 
insist  upon  the  importance  of  careful  inquiry  into  the  family  history 
of  a  patient,  and  into  the  previous  illnesses  that  may  have  occurred 
of  a  similar  nature  to  that  for  which  our  advice  is  sought.  The 
layman  puts  the  same  idea  into  different  words  when  he  exclaims, 
"  The  old  doctor  is  the  man  for  me;  he  understands  my  constitution." 
New  Growths. — Of  the  exact  etiological  factors  underlying  the 
starting  of  a  primary  new  growth,  our  real  knowledge  up  to  now 
amounts  to  —  nil.  Pathologists  were  lately  —  and  perhaps  even 
now  are — keen  in  the  pursuit  of  a  hypothetical  cancer  microbe — 
a  psorosperm,  it  was  called.  If  such  exists,  its  entrance,  its  life,  and 
its  death  are  still  mysteries  to  us.  The  only  clinical  causes  we  can 
yet  appreciate  are  blows  as  the  starting-point  of  many  sarcomata, 
and  chronic  irritation  for  many  epitheliomata,  but  we  still  await 
anything  like  an  explanation  of  the  vast  bulk  of  growths  of  a 
malignant  —  or  innocent,  for  that  matter  —  nature.  Cohnheim's 
theory  of  foetal  remnants  is  perhaps  as  fascinating  as  any ;  but 
even  this  goes  but  a  little  way. 

Processes  of  Disease 

However  few  the  really  independent  causes  of  disease  are  thus 
seen  to  be,  the  individual  morbid  processes  which  they  excite  are 


14  DIFFERENTIAL  DIAGNOSIS  chap. 

still  fewer,  for  they  overlap  one  another  even  more  than  the  causes, 
both  in  their  intermediate  phases  and  in  their  final  results.  Of 
intermediate  phases  only  two  are  possible.  Every  organ  and  tissue 
in  the  body  possesses  two  primary  attributes — structure  and  function, 
— and  the  processes  of  disease  can  only  exhibit  themselves  as  inter- 
ferences with  one  or  the  other,  or  more  probably  with  both,  of  these 
attributes ;  the  diagnosis  and  discrimination  of  these  interferences 
constitute  the  whole  of  our  morbid  anatomy  and  physiology.  With 
microscope  and  naked  eye  we  attempt,  after  death,  or  in  fragments 
removed  from  the  living,  to  find  and  to  study  the  alterations  in 
structure,  and  with  the  clinical  eye  we  endeavour  to  penetrate  the 
mysteries  of  altered  function.  Our  instruments  of  sight,  natural 
and  artificial,  aided  even  by  most  elaborate  staining  processes,  are 
very  imperfect  for  studying  the  finer  —  molecular?  —  structural 
changes,  and  hence,  though  much  has  been  revealed,  very  much 
more  remains  to  be  discovered.  But  the  omissions  are  the  less 
important  from  a  clinician's  point  of  view,  because,  firstly,  we 
cannot  be  sure  that  what  is  seen  was  there  during  life ;  and, 
secondly,  because  of  the  limited  capabihty  of  nature  and  the  still 
more  restricted  power  of  drugs  to  restore  structural  damage,  even 
when  it  can  be  detected  or  surmised.  We  cannot,  moreover, 
determine  what  is  reparable  and  what  is  not,  except  by  that  means 
which  is  our  only  therapeutical  hope,  viz.  by  endeavouring  to 
promote  to  the  utmost  harmonious  function,  the  loss  of  which  is 
indeed  but  too  frequently  our  only  means  of  guessing  that  structure 
has  suffered.  The  power,  on  the  other  hand,  of  the  clinical  eye  is 
only  limited  by  the  amount  and  character  of  the  intelligence  which 
can,  by  reading  and  experience,  be  brought  to  bear  upon  unravelling 
the  intricate  web  and  woof  of  symptoms,  upon  determining  which 
of  them  are  primary  and  essential,  and  which  are  secondary  or  of 
less  moment ;  which  we  can  directly  influence,  and  which  must  be 
left  to  the  control  of  other  organs. 

The  gross  or  comprehensive  processes  by  which  these  inter- 
ferences with  structure  and  function  are  brought  about  are : — 

1.  Inflammation. 

2.  Degeneration. 

3.  New  growths. 

Inflammation. — Into  the  microscopic  details  of  diminished 
drainage  from,  and  excessive  entrance  of  blood  and  serum  into, 
an  inflamed  area  or  organ  I  do  not  propose  here  to  enter,  nor 
into  the  diapedesis  of  white  and  red  corpuscles,  nor  to  the  differ- 


I  DIAGNOSIS  IN  GENERAL  15 

ence  between  these  cells  and  pus,  nor  into  the  vexed  question  of 
the  origin  of  fibroblasts.  Collectively,  all  these  constitute  the  struc- 
tural changes  which  we  can  see,  and  the  student  is  too  apt  to  lose 
himself  in  these  details  of  a  microscopic  slide  and  not  to  think 
of  the  fundio  Icesa  of  vessels  and  tissue  cells  which,  from  the 
medical,  as  opposed  to  the  surgical,  point  of  view,  is  the  chief,  if 
not  the  only,  object  that  requires  attention.  It  is  true  that  we 
frequently  call  upon  a  surgical  colleague,  and  rightly  too,  to  empty 
by  artificial  means  a  serous  cavity  which  has  become  filled  with  the 
products  of  inflammation,  but  it  is  immaterial  to  a  chnician  whether 
the  nucleated  cells  that  appear  at  a  focus  of  inflammation  are  pro- 
fessional policemen  or  special  constables  sworn  in  for  the  occasion  ; 
it  is  immaterial  whether  repair  be  executed  by  builders  called  in 
for  the  purpose  from  a  distance,  or  by  the  inhabitants  living  in  the 
neighbourhood ;  they  all  have  to  be  nourished  by  the  food  in  the 
blood,  they  all  are  worried  by  similar  irritants,  and  our  only  concern 
is  to  remove  the  irritant  as  speedily  as  possible  and  do  our  best  to 
keep  the  blood  in  good  condition. 

The  functio  Icesa  of  capillary  blood-vessels  leads  to  excessive, 
insufficient,  or  improper  food  supply  to,  and  imperfect  drainage 
from,  the  special  or  specific  cells  of  a  part ;  this  leads  to  altered 
vitality  in  these  cells,  and  this  in  turn  is  exhibited  by  disturbance  in 
their  function — excess,  perversion,  or  diminution, — and  eventually, 
if  the  trouble  be  severe  enough  or  long  enough  continued,  the  cells 
die  outright.  It  is  thus  that  we  must  think  of  inflammation  in  its 
earlier  active  phase — kidney  cells  treated  in  this  manner  allow 
wrong  materials,  albumen,  etc.,  to  escape  in  the  urine ;  they  fail  to 
pass  on  the  right  substances,  or  even  cease  to  secrete  at  all ;  hepatic 
cells  cease  their  glycogenic  and  bile  formation  functions,  or  perform 
them  wrongly ;  the  cells  of  the  alimentary  mucous  membrane  ex- 
crete vitiated  digestive  fluids,  and  when  digestion  has  thus  been 
improperly  performed,  absorption  becomes  a  harmful  process,  the 
gut  muscle  too  is  hurried  into  excessive  action,  and  diarrhoea 
ensues,  or,  if  it  be  involved  seriously  in  the  trouble,  its  function 
ceases,  and  paralytic  obstruction — the  most  serious  of  all  forms  of 
recoverable  obstruction — occurs ;  in  the  lungs  excessive  secretion 
or  effusion  fills  the  air  cells,  and  thus  brings  about  cessation  of  the 
aerating  function ;  imperfect  nutrition  of  nerves  sends  them  astray 
in  functioning,  and  their  property  of  irritability  becomes  excessive, 
insufficient,  or  perverted,  and  so  the  illustrations  might  proceed 
through  the  body. 

The  fimctio  Icesa   of  the  tissue  cells  may  thus  be  secondary  to 


1 6  DIFFERENTIAL  DIAGNOSIS  chap. 

that  of  the  capillaries,  but  more  frequently  in  medical  practice  we 
see  it  as  a  primary  phenomenon  due  to  a  toxic  condition  of  the 
nourishing  plasma  which  surrounds  them ;  under  these  circum- 
stances the  cells  cease  to  a  large  extent  their  own  specific  activities 
and  take  up  ones  that  are  foreign  to  them,  manufactory  of  an  anti- 
toxin and  other  unusual  metabolic  processes.  When  thus  struggling 
against  unnatural  conditions  they  are  very  liable  to  be  attacked  by 
fatal  structural  changes  unless  relief  be  speedily  afforded  them.  It 
is  thus  I  understand  the  evil  effects  of  the  working  of  blood- 
poisoning,  whether  this  be  generalised  over  the  whole  body,  as  in 
zymotics,  or  whether  it  arise  from  some  quite  localised  process,  as 
in  a  poisoned  wound  with  absorption  therefrom. 

When  these  destructive  phases  of  inflammation  have  ceased  and 
nature  exhibits  her  limited  power  of  parenchymatous-cell  reproduc- 
tion, we  must  remember  that  the  new  or  young  cells  have  to  learn 
their  business  and  get  accustomed  to  variations  in  their  environ- 
ment ;  they  are  likely  at  first  to  be  of  feeble  vitality  and  resisting 
power,  and  chronic  exfoliation  may  thus  be  kept  up  till  irreparable 
damage  is  done  to  the  organ  of  which  they  form  the  essential 
constituent. 

And  lastly,  when  repair  is  complete  we  have  to  realise  the 
strangling  effects  of  the  new-formed  fibrous  tissue,  which,  in  us,  is 
the  best  that  nature  can  do  to  fill  up  a  gap.  This  fibrous  tissue 
cannot  pick  out  urea  nor  biliary  constituents  from  the  blood,  it 
cannot  absorb  peptones  or  fats  or  oxygen,  it  cannot  transmit 
messages,  nor  can  it  contract  and  relax  in  response  to  messages 
received ;  it  has  only  one  function,  that  of  contraction  into  a  con- 
dition of  stable  equilibrium,  and  this  it  exercises  with  most  per- 
nicious effects  on  vessels  and  parenchymatous  cells,  strangling  the 
one  and  starving  the  other. 

I  have  written  at  some  little  length  on  the  local  processes  of 
inflammation  in  the  hope  of  making  it  clear  that  a  scar  in  the 
kidney  is  identical  with  one  in  the  lung  or  liver,  that  a  catarrh  of  the 
bronchi  is  identical  in  its  processes  with  one  of  the  gut ;  that, 
in  fact,  the  principles  once  grasped,  details  can  be  evolved  with 
readiness  for  special  cases,  and  pathology  thus  changed  from  a 
heterogeneous  collection  of  wearying  facts  to  a  splendid  illustration 
of  fundamental  laws  working  on  lines  variable  within  small  and 
special  limits. 

Degeneration. — In  text-books  of  pathology  it  is  usual  to  de- 
scribe this  process  as  either  a  primary  or  a  secondary  phenomenon, 
and  then  to  give   particulars  of  many  varieties  :    amyloid,  brown. 


I  DIAGNOSIS  IN  GENERAL  17 

glassy,  cloudy,  fatty,  mucoid,  colloid,  fibroid,  etc.  Important  as 
this  knowledge  is  from  many  points  of  view,  it  may  for  our  present 
purposes  be  largely  ignored,  for  both  forms  and  all  varieties  mean 
cHnically  very  much  the  same  thing,  viz.  diminution  in  vitality  and 
functional  capacity,  and  ultimately  death,  of  the  parenchymatous 
cells,  whose  fate  is  being  discussed. 

The  primary  form,  strictly  speaking,  has  for  its  underlying 
essence  either  natural  wear  and  tear,  or  congenital  and  inherent 
poor  quality  of  material,  both  of  which  have  been  already  alluded 
to  as  primary  causes  of  disease ;  but  it  is  usual  in  clinical  medicine 
to  think  of  and  accept  as  primary  many  varieties  of  degeneration, 
fatty,  etc.,  which  are  in  reality  induced  by  an  insidious  form  of  chronic 
poisoning  or  starvation  through  the  blood  supply,  which  in  its  turn 
is  influenced  primarily  by  the  alimentary  canal  and  the  substances 
put  into  it  and  absorbed  thence.  These  are  thought  of  as  primary 
because  it  is  difficult,  and  perhaps  impossible,  in  some  cases  to 
appreciate  the  alimentary  errors  which  are  at  the  bottom  of  the 
matter.  In  other  cases  of  so-called  primary  degeneration  typically 
in  the  nervous  system  the  death  of  the  (neuron)  cell,  and  the  con- 
sequent atrophy  and  degeneration  of  its  processes,  may  be  brought 
about  by  the  agency  of  very  insidious  microbic  toxins,  syphilitic  for 
example.  This  probably  is  the  explanation  of  many  cases  of  tabes 
dorsalis,  and  other  primary  affections  of  the  nervous  system  not 
directly  traceable  to  inherent  weakness. 

To  see  with  the  actual  or  with  the  clinical  eye  the  process  of 
secondary  degeneration  is  usually  comparatively  easy  and  simple ; 
for  whereas  in  the  primary  form  the  trouble  arose  from  insidious 
qualitative  changes  in  the  supply  of  nutriment  and  the  removal  of 
waste,  here  it  is  due  either  to  a  gross  interference  with  the  quanti- 
tative nutritive  supply,  or  to  an  equally  gross  mechanical  interference 
with  the  protoplasm  of  the  cells — squeezing  or  distortion.  A  few 
illustrations  will  make  the  position  clearer.  The  absolute  block- 
ing of  a  large  (or  microscopical)  artery  by  thrombos  is,  embolus,  or 
ligature,  leading  to  coarse  (or  fine)  gangrene  or  necrosis  of  tissue, 
is  the  most  obvious  illustration  of  the  former  process.  It  is  well 
seen  and  very  common  in  the  brain,  spleen,  kidney,  or  lung.  It 
occurs,  though  less  commonly,  in  the  intestine,  liver,  and  other 
organs  (in  surgery  it  is  common  enough  in  limbs,  or  part  of  them). 
The  secondary  degeneration  of  the  processes,  long  and  short,  of 
the  neuron  cells  of  the  nervous  system  is  a  less  obvious  but  equally 
certain  illustration  ;  it  differs  in  that  the  nutritive  supply  or  stimulus 
reaches  the  process  (and  indeed  probably  also  gland  cells,  muscles, 

c 


1 8  DIFFERENTIAL  DIAGNOSIS  chap. 

etc.)  through  other  channels  than  obvious  vessels,  but  the  degener- 
ative result  follows  as  surely  as  does  general  wasting  of  the  body  at 
large  when  the  stomach  is  seriously  incapacitated.  The  actual 
rupture  of  a  vessel  may  act  in  both  ways ;  it  is  certain  that  the 
blood  supply  to  the  part  concerned  is  stopped,  and  at  the  same 
time  the  blood,  escaping  from  the  vessel  often  at  high  pressure, 
mechanically  tears  asunder  the  cells  of  the  tissue  and  exposes  them 
to  every  form  of  distortion  and  violence.  Inflammation,  again,  in 
its  reparative  stages,  is  a  potent  cause  of  secondary  degeneration 
through  the  cell  strangulation  its  scar  contraction  brings  about 
(in  its  acute  destructive  phases  the  destruction  is  wrought  by  the 
action  of  poisons  and  excessive  reaction  to  them),  and  this  not  only 
in  gross  cases  of  localised  trouble,  but  also  in  the  more  chronic  and 
diffused  forms,  as,  for  example,  in  cirrhosis  of  the  liver  of  alcohohc 
origin,  in  pneumonokoniosis  and  other  forms  of  cirrhosis  of  lung. 
The  influence  of  cardiac  disease  {q.v.\  with  its  back-pressure  stagna- 
tion and  increased  transudation  from  the  capillaries,  acts  in  a  very 
similar  manner  to  the  diffuse  forms  of  inflammation — loss  of  function, 
then  death,  with  a  very  imperfect  or  altogether  absent  power  of 
reproduction  of  cells  of  highly  speciaHsed  function,  this  in  turn 
followed  by  a  fine  fibrosis  to  fill  the  spaces  left  by  the  absorption 
of  dead  cells — these  are  the  processes  induced  in  organs  and  tissues 
by  cardiac  failure. 

New  Growths. — But  one  diagnostic  difficulty  here  presents 
itself,  and  that  is  of  establishing  by  physical  signs  the  presence  of  a 
malignant  growth.  This  is  frequently  great,  and  sometimes  even 
insuperable  without  surgical  aid  (will  the  Rontgen  rays  ultimately 
assist  us  here  ?) ;  but  whether  this  difficulty  be  overcome  or  not, 
the  pathological  processes  which  a  maHgnant  growth  starts  in  the 
body  are  comparatively  simple  to  understand.  Thus  a  malignant 
growth  acts : — 

Mechanically         \  coarsely 

or  >  or 

biologically  )         insidiously. 

Of  the  coarse  mechanical  form  of  trouble  the  blockage  of  a 
hollow  tube,  either  by  projection  into  its  lumen  or  by  pressure  from 
without,  is  at  once  the  simplest  and  most  common  illustration.  Thus 
the  intestine,  ureter,  or  bile-duct  may  be  blocked,  and  gastric  dis- 
tension, with  vomiting  and  emaciation,  or  intestinal  obstruction, 
with  retention  and  absorption  of  faecal  products,  occur,  or  retention 
of  urine  or  bile,  with  a  more  or  less  rapidly  following  toxaemia  by 


I  DIAGNOSIS  IN  GENERAL  19 

products  that  should  be  discharged  from  the  body.  Arteries,  capil- 
laries, veins,  and  lymphatics  suffer  in  precisely  the  same  way,  with 
resulting  anosmia,  or  even  gangrene,  oedema,  or  effusion,  simple  or 
chylous,  according  to  the  function  of  the  blocked  vessel.  Solid 
organs,  too,  may  suffer  from  the  same  gross  pressure,  with  disturb- 
ance of  function  and  distortion  of  structure.  The  brain  gives  us  a 
common  illustration  of  this  class,  but,  owing  to  the  fact  that  it,  with 
its  vessels  of  all  kinds,  are  enclosed  in  an  unyielding  box,  the 
results  are  complicated,  for  they  may  be  due  to  direct  pressure  on 
specialised  cells,  as  well  as  to  indirect  effects  of  altered  circulation. 

More  insidious,  but  equally  real,  mechanical  (pressure,  strangu- 
lation, disturbed  circulation)  effects  are  produced  by  the  creeping 
processes  of  the  growth,  and  explain  the  symptoms  and  cause  of 
death  in  many  cases,  thus  in  the  lung  and  liver,  structure  and 
function  frequently  suffer  far  out  of  proportion  to  the  naked-eye 
bulk  of  the  tumour.  In  the  intestine  the  muscle  is  paralysed  by 
these  processes,  and  so  contributes  by  this  paralysis  a  large  share 
to  the  obstruction.  In  the  brain,  too,  it  is  thus  that  we  must 
explain  the  fatal  effects  of  a  small  tumour  growing  into  a  very  im- 
portant area  of  the  organ.  This  insinuation  of  the  growth  into  a 
tissue,  with  violent  separation  of  the  elements,  frequently  sets  up  a 
diffuse  inflammatory  reaction  in  the  cells  of  an  organ,  and  this  must 
also  be  reckoned  amongst  the  insidious  mechanical  effects. 

The  biological  or  vital  morbid  processes  started  by  and  in 
tumours  would  seem  to  depend  somewhat  upon  what  we  may  call 
the  physiology  of  new  growths,  which  may  be  thus  summarised : — 

1.  They  possess  a  great  power  of  increase  in  bulk,  or  vitality  of 
reproduction. 

2.  They  would  seem  to  possess  some  form  of  internal  secretion 
or  metabolic  activity  whereby  chemical  products  are  poured  into 
the  blood  stream  —  products  which  are  foreign  to  the  normal 
tissues,  and  apparently  of  considerable  power  for  evil  in  some  cases. 

3.  They  appear  to  possess  but  little  or  even  no  power  of  resist- 
ance against  irritative,  especially  microbic,  influences. 

(i)  has  already  been  considered  as  starting  all  the  mechanical 
effects,  both  gross  and  fine,  of  tumours.  It  also  explains  (microbio- 
logical researches  may  alter  in  some  ways  this  view)  the  phenomena 
of  recurrence  after  appai^ejit  extirpation,  and  metastases  due  to  the 
transference  from  place  to  place  of  cells  endowed  with  this  special 
power  of  reproduction. 

(2)  would  appear  in  some  measure  to  explain  the  anaemia  and 
cachexia  which  frequently,  but  by  no  means  invariably,  accompany 


20  DIFFERENTIAL  DIAGNOSIS  chap,  i 

the  existence  of  a  malignant  growth.  Starvation  and  the  mechanical 
effects  mentioned  above  doubtless  play  the  chief  role,  but  many 
cases  occur  in  which  these  are  not  sufficient  to  explain  the  great 
cachexia  occasionally  met  with  even  when  the  growth  does  not 
affect  an  important  organ.  Thus  does  a  growth  insidiously  under- 
mine health. 

{3)  It  is  to  the  feebleness  of  the  powers  of  resistance  (the  pro- 
tective reaction  to  irritation  possessed  by  normal  tissues)  must  be 
largely  attributed  the  ease  with  which  malignant  growths  become 
the  seat  of  destructive  phases  of  inflammation,  with  but  little  cor- 
responding power  of  allowing  or  promoting  the  reparative  phases. 
When  microbes  invade,  as  tl^ey  so  frequently  do,  malignant 
neoplasms,  they  are  but  seldom  killed  by  the  growth,  or  even 
diminished  in  vitality,  and  thus  it  very  frequently,  indeed,  happens 
that  secondary  septic  processes  carry  off  a  patient  who  begins  by 
suffering  from  carcinoma ;  thus  in  epithelioma  of  the  lips  or  tongue 
death  is  very  often  due  to  inspiration-pneumonia ;  and,  indeed,  in 
carcinoma  of  the  lung  it  is  as  often  as  not  a  pneumonia  that  finishes 
the  scene.  In  carcinoma  of  the  gut,  peritonitis  is  to  be  feared  long 
before  perforation  can  occur,  as  though  the  growth  encouraged  the 
penetration  of  microbes  or  their  toxins.  Such  exhibitions  may  with 
justice  be  termed  the  grosser  forms  of  biological  active  processes 
induced  by  growths,  an  empyema  or  a  purulent  peritonitis  being 
the  immediate  diagnosis. 

We  have  thus  completed  an  outline  sketch  of  the  primary  causes 
and  processes  of  disease.  From  these,  physiological  deduction  will 
lead  us  to  expect  certain  morbid  phenomena  as  the  result  of  certain 
untoward  influences  in  our  environment.  We  must  now  proceed 
to  discuss  diagnosis  by  inductive  methods,  accepting  the  morbid 
phenomena  (the  physical  signs  and  symptoms  discovered  in  or  com- 
plained of  by  our  patients)  as  the  threads  of  Penelope  to  lead  us 
out  of  the  maze,  or  to  discover  the  fountain-head,  and  thus  apply 
therapeutical  measures  with  some  idea  of  what  results  we  hope  or 
intend  to  produce. 


CHAPTER   II 

notes  on  a  few  of  the  terms  used  in  medicine  and 
medical  diagnosis 

Physical  Signs  v.  Symptoms 

Symptoms  are  those  uneasy  or  abnormal  sensations  or  feelings 
of  which  the  patient  complains  either  spontaneously  or  as  the  result 
of  verbal  inquiry,  e.g.  pain,  cough,  shortness  of  breath  on  exertion, 
etc.  It  is  customary  also  to  include  many  other  phenomena  in  the 
term,  such  as  the  results  obtained  by  chemical,  bacteriological,  or 
microscopical  research,  and  even  some  unusual  conditions  of  the 
nervous  system  assuredly  only  found  by  physical  examination,  e.g. 
absent  knee  jerks,  etc.,  but  I  think  it  well  to  have  a  sharp  line  of 
distinction  where  possible. 

Physical  signs  is  a  term  used  to  describe  those  phenomena  of 
disease  (especially  of  the  chest  and  abdomen)  which  only  become 
apparent  to  the  observer's  senses  by  means  of  what  is  termed  a 
physical  examination,  including,  in  its  completest  extent,  inspection, 
palpation,  percussion,  and  auscultation  in  their  simple  and  modified 
{e.g.  succussion)  forms. 

If  these  definitions  are  not  in  every  particular  absolutely  satis- 
factory, they  at  least  form  a  sound  and  workable  conception  for 
clinical  purposes.  That  some  such  definition  as  the  above  is  useful, 
my  own  experience  would  tend  to  show,  for  I  have  been  asked  the 
distinction  between  the  two  sets  of  phenomena  in  a  court  of  law, 
and  it  is  no  unfrequent  occurrence  for  a  student  to  glibly  enumerate 
a  string  of  the  easier  and  less  important  physical  signs  when  asked 
for  the  more  perplexing  and  intricate,  and  withal  more  germane, 
symptoms,  a  reply  which  may  not  unfairly  be  allowed  to  annoy  an 
examiner  and  create  in  his  mind  a  bad  impression  of  a  candidate's 


22  DIFFERENTIAL   DIAGNOSIS  chap. 

clinical  knowledge.  Nevertheless,  it  must  be  borne  in  mind  that 
neither  in  science  nor  in  ordinary  usage  is  there  a  fundamental  dis- 
tinction based  on  clear  conceptions  of  existing  facts.  For  example, 
pain  may  certainly  be  claimed  as  a  symptom,  and  cardiac  bruits  as 
physical  signs,  but  what  shall  we  say  of  the  pain-drawn  face,  or  the 
cardiac  bruit  that  is  audible  and  troublesome  by  its  noise  to  the 
patient  ?  It  follows  clearly  that  where  no  pressure  from  counsel  or 
examiner  is  brought  to  bear,  the  two  terms  will  be  used  almost  indis- 
criminately. 

Pathology 

No  term  in  medical  science  is  used  in  such  a  loose  sense,  and 
with  so  many  confusing  ideas  attached  to  it,  as  this,  and  one  cannot 
wonder  at  the  student's  difficulties  in  trying  to  answer  a  question 
such  as,  "  Give,  describe,  or  state  what  you  know  of  the  pathology 
of  such  and  such  a  disease."  "  A  chat  about  the  etiology  "  seems 
at  first  sight  to  be  a  very  happy  definition,  but  frequently  the  term 
is  used  much  more  or  much  less  comprehensively. 

It  cannot  be  too  strongly  insisted  upon  that  there  are  at  least 
three  separate  and,  in  some  respects,  different  and  distinct  ideas 
contained  in  the  word  as  commonly  employed  :  — 

1.  The  changes  in  organs,  tissues,  and  fluids  of  the  body  to  be 

found  by  the  naked  eye  and  microscope  after  death  = 
morbid  anatomy. 

2.  The  explanation  of  symptoms  (and  often,  indeed,  of  physical 

signs  also)  by  reference  to  the  known  morbid  anatomy ; 
this  =  morbid  physiology  or  the  etiology  (from  within)  of 
symptoms  =  symptomatology. 

3.  The  explanation  of  the  morbid  anatomy  or  morbid  physi- 

ology by  reference  to  the  action  or  influence  of  the  en- 
vironment on  the  organism  =  etiology  (from  without)   of 
disease. 
That  all  these  three  meanings  may  simultaneously  be  read  into 
the  word  is  obvious  from  its  derivation  (ttci^os  and  Aoyos),  the  theory 
of,  or  a  discourse  on,  suffering;  but  its  everyday,  and  especially  its 
examinational,  meanings  are  ill  defined.     For   instance,  the   path- 
ology of  inflammation  chiefly  concerns  itself  with  the  naked  eye, 
and  especially  the  microscopical  anatomy  of  the  inflamed  area  and 
the  changes  going  on  in  its  neighbourhood,  together  with  specula- 
tions as  to  the  precise  origin  of  the  cells  seen.     The  pathology  of 
gout,  diabetes,  and  blood  dyscrasias  in  general,  principally  requires 


II  TERMS  USED  IN  MEDICAL  DIAGNOSIS  23 

a  discussion  of  the  primary  seat  of  perverted  metabolism,  with  a 
hypothetical  explanation  of  the  morbid  physiological  phenomena 
which  arise  in  consequence  of  this  perversion,  morbid  anatomical 
facts  receding  in  the  background  as  results  rather  than  causes ; 
while,  again,  the  pathology  of  pneumonia  or  other  specific  fever 
would  be  very  incomplete  without  considerable  reference  to  the 
micro-organisms  which  cause  them,  and  the  modes  by  which  these 
parasites  enter  the  body  and  attack  the  tissues. 

If  no  suggestions  are  given  as  to  the  precise  form  of  answer 
required,  a  clear  exposition  of  the  pathology  of  any  disease  is  best 
given  by  a  brief,  concise,  but  complete  as  possible,  summary  of  the 
main  (anatomical,  symptomatic,  and  etiological)  facts  observed  in 
its  history,  followed  by  a  statement  or  discussion  of  those  theories 
which  have  been  propounded  as  best  explaining  or  Hnking  together 
these  facts. 

As  an  example  we  may  sketch  an  answer  to  the  question, 
"  What  is  the  pathology  of  cirrhotic  kidney  ?  " 

The  most  important  facts  observed  in  connection  with  cirrhotic 
kidney  are  : — 

A.  Anatomical. — The  almost    universal    discovery  on  autopsy 

that  hypertrophy  of  the  heart  and  degeneration  of 
arteries  have  coexisted  with  the  cirrhotic  kidneys. 

B.  Symptomatic. — The  extreme  frequency  w^ith  which  patients 

thus  afflicted  suffer,  and  even  die,  from  uraemia,  cerebral 
haemorrhage,  or  intercurrent  inflammation  of  some  organ. 
The  condition  of  the  urine. 

C.  Etiological. — That  such  patients  are  almost  invariably  at  or 

past  middle  age,  or  have  been  gouty,  or  suffered  from 
plumbism,  or  suffered  from  repeated  attacks  of  acute  or 
subacute  nephritis. 

The  theories  suggested  to  account  for  the  anatomy  are:  (i) 
Johnson's  stopcock  theory.  (2)  Gull  and  Sutton's  arterio-capillary 
fibrosis.  "  Renal  inadequacy "  (a  term  associated  with  the  late 
Sir  Andrew  Clark),  especially  if  of  long  duration,  will  largely  account 
for  the  symptoms,  while  the  condition  of  the  kidneys,  as  revealed 
by  the  microscope,  give  a  sufficient  explanation  of  this  renal 
inadequacy. 

Or,  to  take  a  shorter  example,  the  pathology  of  Addison's 
disease : — 

The  only  constant  anatomical  fact  is  destruction  of  the  supra- 


24  DIFFERENTIAL  DIAGNOSIS  chap,  ii 

renal  organs,  and  that  almost  constantly  of  a  caseous,  probably 
tubercular,  nature. 

Pigmentation  of  the  skin  is  not  nearly  so  constant. 

Symptomatic  facts  are  few  and  summed  up  in  progressive 
debility  and  frequent  gastric  crises  and  a  very  poQr  pulse. 

Etiological  facts  none  constant,  but  tubercle  bacilli  often  found 
in  the  glands. 

A  theory  has  then  to  be  stated  and  argued  out  as  to  the  func- 
tions of  the  suprarenals,  interference  with  which  can  produce  these 
symptoms  ;  it  must  be  compatible,  too,  with  the  fact  that  destruction 
of  the  organs,  other  than  tuberculo-caseous,  frequently  enough  does 
not  produce  the  same  symptoms. 

Contagion  v.  Infection 

These  terms  are  often  used  to  indicate  different  methods  by 
which  a  disease  is  communicated  from  person  to  person.  Unfor- 
tunately (as  is  so  often  the  case  with  terms  originally  possessing  one 
specific  meaning),  habit  and  common  usage,  but  especially  increased 
recognition  of  facts,  have  so  broken  down  the  limits  between  the 
meanings,  that  the  words  now  only  remain  as  puzzles  for  students. 
Contagion  should  mean  transference  by  actual  contact  of  person 
with  person,  while  infection  should  be  a  more  comprehensive  term, 
indicating  that  the  disease  to  which  the  adjective  "  infectious  "  is 
applied  can  be  communicated  from  one  individual  to  another,  and 
should  include  contact  as  one  method  of  such  communication.  The 
essential  fact  of  clinical  importance  is  the  communicability  of  the 
disease;  observation  and  laboratory  work  must  teach  us  the  ^^how" 
leaving  the  clinician  to  use  such  expressions  as  "  communicated  by 
contact,"  or  "  by  microbes  floating  in  the  air  and  gaining  entrance 
to  a  second  individual  either  by  means  of  milk,  water,  food,  or  by 
the  breath,  etc."  Such  expressions,  if  cumbersome,  at  any  rate 
convey  a  definite  meaning ;  and  until  science  supplies  us  with  more 
accurate  knowledge,  "  communicable  "  is  quite  sufficiently  under- 
stood to  include  all  such  terms  as  contagious,  infectious,  etc. 


CHAPTER   III 

MICRO-ORGANISMS    AND    ZYMOTIC    DISEASES 

From  communicable  diseases  to  microbes  is  nowadays  Hardly  a  step 
in  thought,  for  the  researches  of  the  last  quarter  of  a  century  have 
taught  us  that  the  two  are  essentially  effect  and  cause.  In  this 
work,  dealing  mainly  with  clinical  problems  and  practical  medicine, 
I  do  not  propose  to  give  more  than  the  very  briefest  outline  of 
those  fundamental  principles  of  bacteriology  which  have  now"  be- 
come essential  for  all  medical  practitioners.  Beyond  those  principles 
and  their  correct  understanding  I  do  not  hold  that  it  is  necessary, 
or  even  desirable,  that  students  or  medical  men  in  practice  should 
go ;  the  extraordinary  intricate  details  and  scrupulous  exactitude 
required  for  the  scientific  laboratory  working  of  bacteriology  are  too 
engrossing  for,  and  demand  too  much  time  from,  those  who  do  not 
intend  to  devote  their  life  to  purely  scientific  work  of  this  descrip- 
tion. The  healers  of  the  sick  must  patiently  wait  for  the  results  of 
laboratory  work,  recognising  and  using  those  which  are  immediately 
available  for  practice.  These  already  represent  a  greater  amount  of 
accurate  and  minute  knowledge  of  the  causes  and  processes  of 
disease  than  all  the  previous  centuries  have  yielded. 

Meanwhile  the  following  numbered  paragraphs  contain  the 
principles  of  the  subject  in  a  form  easily  assimilable,  and  only  to  be 
acquired  from  monographs  by  a  very  tedious  process  of  analysis. 

.  I.  Micro-organisms  do  exist  in  countless  myriads  everpvhere  in 
nature  where  the  conditions  of  moisture,  temperature,  and  access  of 
air  are  suitable. 

2.  Their  genera  and  species  are  probably  more  numerous  than 
those  of  all  animals  or  plants  visible  to  the  naked  eye. 

3.  They  are  too  small  to  show  generic  or  specific  distinctions 


2  6  DIFFERENTIAL  DIAGNOSIS  chap. 

in  their  organs,  consequently  the  classification  of  them  for  scientific 
purposes  rests  on  : — 

{a)  Gross  outward  shape — cocci,  bacteria,  bacilli,  spirillum,  etc. 

{b)   Their  methods  of  aggregation  and  segregation. 

{c)    Motility  or  the  reverse. 

{d)  Their  chemical  and  vital  reactions  to  and  on  their  artificial 
environment,  e.g.  aerobic  or  an^robic,  whether  they  liquefy 
gelatine  with  or  without  the  production  of  gas,  or  whether 
they  do  not  liquefy  it,  what  nutrient  medium  do  they 
best  flourish  in  or  on ;  colour  and  appearance  of  the 
growth,  etc.,  etc. 

{e)  Their  reactions  to  various  staining  and  decolourising  re- 
agents. 

(/)  And  most  importantly,  their  influence  upon  their  host  after 
inoculation  into  a  vein  or  tissues  or  serous  cavity,  etc., 
e.g.  whether  they  produce  any  symptoms  of  ill-hfealth  or 
not,  the  character  of  the  symptoms,  and  the  anatomical 
results  on  autopsy  of  the  animal,  etc.  In  this  way 
they  have  been  divided  into  two  broad  groups,  the 
pathogenic  and  the  non-pathogenic,  a  distinction  which 
frequently  breaks  down  when  microbes  gain  access  to  a 
part  of  the  body  in  which  they  are  not  usually  found, 
e.g.  the  bacterium  coh  commune  is  a  natural  inhabitant 
of  the  alimentary  canal,  but  it  seems  to  cause  very  serious 
mischief  when  it  gets  into  the  tissues  generally. 

4.  Those  now  known  to  produce,  and  generally  accepted  as 
producing,  disease  (the  pathogenic  group),  constitute  probably  only 
a  minute  fraction  of  the  whole  number  of  species. 

5.  To  prove  that  one  particular  microbe  and  no  other  is  the 
cause  of  a  given  disease  or  symptom-complex,  the  following  condi- 
tions must  be  rigorously  fulfifled  : — 

(a)  It  must  be  constantly  found  in  the  blood,  tissues,  or  dis- 
charges of  the  individuals  suffering  from  the  disease  in 
question, 

{b)  From  this  source  a  culture  must  be  prepared  in  a  sterile 
medium,  and  the  particular  microbe  isolated  and  grown 
in  pure  culture  for  some  generations. 

{c)  From  such  absolutely  pure  culture  it  must  be  introduced 
into  a  fresh  healthy  individual  of  the  same  species  as  the 
original  sufferer. 


Ill       MICRO-ORGANISMS  AND  ZYMOTIC  DISEASES       27 


{d)  This  inoculation  must  reproduce  the  disease  in  the  second 
individual. 

(e)  The  special  microbe  must  again  be  found  in  the  second 
animal  in  the  same  situations  as  before. 

In  the  strict  fulfilment  of  these  laws  are  contained  all  the 
difficulties  of  scientific  bacteriology.  They  can  only  be  appreciated 
by  those  of  experience,  and  to  publish  the  crude  and  inaccurate 
results  of  the  dabblers  in  the  science  is  merely  to  waste  paper,  and 
to  retard  the  progress  of  medicine. 

6.  AppHed  to  man  and  practical  medicine  there  is  only  one 
microbe  which  has  gone  completely  through  the  trial  and  come  out 
triumphant,  that  is  the  organism  w^hich  produces  cutaneous  erysipelas. 
The  reason  why  no  others  have  been  intentionally  put  to  the  test  is 
self-obvious ;  but  laboratory  accidents  (only  too  frequently),  experi- 
ments on  animals,  and  justifiable  deduction  have  so  far  proved  the 
position  as  to  leave  no  reasonable  doubt  that  a  microbe  is  at  the 
bottom  of  the  following  w^ell-known  diseases  : — 


Group  I 


Tuberculosis    (of    every    form 

and  organ). 
Pneumonia  (?  one  only). 
Anthrax. 
Typhoid. 
Asiatic  cholera. 
Diphtheria. 
Malaria. 
Leprosy. 

Gonorrhoea  (.''  one  only). 
Rabies. 
Tetanus. 
Plasrue. 


Of  which  it  may  be  said  that  the 
type  of  the  disease  is  fairly  con- 
stant, and  that  one  special  microbe 
has  been  identified  and  universally 
accepted  as  the  essential  cause  of 
the  malady. 


Group  II 


Cerebro-spinal  meningitis. 

Dysentery. 

Influenza. 

Measles. 

Scarlet  fever. 

Small-pox. 

Typhus. 

Varicella. 

Whooping  cough. 

Syphilis. 


Of  which  we  may  say  that  the  con- 
ditions and  circumstances  under 
which  they  occur,  together  with 
the  regularity  of  their  symptoms, 
leave  no  reasonable  doubt  about 
each  being  caused  by  a  definite 
species  or  genus  of  microbe, 
though  such  has  not  yet  been 
satisfactorily  isolated  so  as  to  be 
universally  accepted. 


28  DIFFERENTIAL  DIAGNOSIS  chap. 

Group  III 

Pycemia.  )       The  diseases  hitherto  enumerated  under  lists  I  and 

Septicaemia,    j  II  have  a  group  of  symptoms  and  dinical  courses 

which  are  so  far  constant  and  distinctive  (rash,  periodicity,  anatomical 
products,  etc.)  as  to  deserve  a  specific  and  constant  name,  and  to  lead 
to  the  belief  that  one,  and  one  only,  species  of  microbe  is  the  causa 
causans.  In  these  two  diseases,  on  the  other  hand,  the  symptoms 
(fairly  constant,  but  with  no  absolutely  pathognomonic  feature),  the  course, 
and  careful  bacteriological  investigation,  all  tend  to  raise  a  conviction 
that  more  than  one,  if  not  indeed  several,  species  of  microbes  may  be 
concerned.  To  satisfactorily  and  simply  account  for  the  manufacture  of 
the  words  it  is  necessary  to  state  briefly  the  clinical  classification  of 
pathogenic  micro-organisms. 

For   this    purpose,    then,    we    may    divide    them    into    three 

classes  : — 

(a)  Those  which,  under  any  circumstances  of  the  patient,  are 
able  after  entry  to  the  body  to  grow  into,  attack,  and  destroy  healthy 
tissues,  and  hence  can  be,  and  are,  easily  carried  by  the  blood- 
stream to  distant  parts  of  the  body. 

ip)  Those  which,  under  no  known  circumstances  of  the  patient, 
are  able  thus  to  attack  healthy  tissues,  but  cause  symptoms  by 
living  and  growing  on  dead  or  dying  tissues,  and  from  there  dis- 
charging into  the  blood-stream  doses  of  a  chemical  poison  extremely 
active,  indeed,  but  incapable  of  multiplication. 

ic)  Those  which  seem  to  be  of  an  intermediate  character,  and 
depend  for  their  activity  and  virulence  to  a  large  extent  upon  the 
conditions  of  vitality  of  the  tissues  upon  which  they  alight,  and  also 
on  their  own  temporary  condition  of  vigour. 

Pyaemia,  then,  is  a  disease  produced  by  a  member  of  class  (a), 
and  in  strictness  must  include  anthrax,  and  nearly  all  the  other 
specific  diseases. 

Septicaemia  is  a.  disease  produced  by  a  member  of  class  (^). 

Artificial  cultivations  and  experimental  inoculations  would  seem 
to  show  that  between  all  three  groups  no  line  of  strict  demarca- 
tion can  be  drawn ;  but  this  does  not  entirely  destroy  the  clinical 
value  of  the  distinction  in  cases  of  disease.  For  when  in  a  natural 
state  the  distinction  can  be  moderately  well  made,  and  it  is  prob- 
able that  clinical  (as  opposed  to  laboratory  experimental)  diseases 
arise  from  the  invasion  of  microbes  of  a  natural  (to  them)  healthy 
activity. 

7.  Pathogenic  microbes  would  seem  to  be  able  to  attack  tissues 


Ill       MICRO-ORGANISMS  AND  ZYMOTIC  DISEASES       29 

in  one  or  both  of  two  primary  ways  with  a  subdivision  of  the 
second  method. 

(a)  By  a  sort  of  hand-to-hand  fight,  microbe  v.  cell  =  phago- 
cytosis. 

(^)  By  a  weapon  in  the  shape  of  a  secretion  =  chemiotaxis, 
about  which  weapon  two  theories  exist : — 

(i)  The  secretion  is  itself  a  poisonous  chemical  substance  = 

a  toxin. 
(2)  The  secretion  is  of  the  nature  of  a  ferment,  comparable 

to  trypsin,  say,  and  =  a  toxinogen. 

On  the  other  hand  the  cell  defends  itself  either — 

(i)  By  bodily  eating  the  microbe. 

(2)  By  secreting  a  substance  neutralising  the  toxin,  or  fer- 
ment, or  the  products  of  the  ferment ;  in  either  case  it 
is  called  an  antitoxin. 

This  is  the  most  natural  place  in  which  to  insert  the  clinical 
reasons  for  suspecting  that  a  disease  is  due  to  microbial  influences. 

(a)  The  occurrence  of  an  epidemic  of  the  disease  in  question, 
in  which  the  logic  of  events  seems  to  prove,  or,  at  least,  strongly 
suggest,  that  on  the  one  hand  all  the  cases  arise  from  a  common 
(aerial,  aquatic,  or  telluric)  source,  from  which  all  gross  metallic, 
e.g.  lead,  copper,  arsenic,  mercury,  or  organic,  e.g.  decomposing 
food,  poisons  can  be  and  are  excluded ;  or  on  the  other  hand 
that  consecutive  cases  arise  from  previous  ones,  the  latter  a  mode 
of  spreading  often  better  noticed  in  the  smaller  sporadic  outbreaks, 
where  observation  is  closer  and  the  methods  of  "  catching "  the 
complaint  more  easily  distinguished. 

(d)  The  existence  of  localities  where  endemic  diseases  flourish, 
where  a  purely  local  cause  must  be  at  work,  but  where,  again,  all 
metallic  and  ordinary  organic  chemical  poisons  can  be  excluded. 

(c)  In  both  these  cases  the  a  priori  argument  will  be  enormously 
strengthened  by  a  posteriori  reasoning  when  the  common,  local,  or 
personal  factor  has  been  removed,  and  the  disease  has  ceased  to 
attack  fresh  individuals,  and  the  removed  factor  has  been  shown  to 
contain  no  organic  or  metallic  poison. 

{d)  The  character  of  the  disease  itself  an  active  acute  onset, 
follovred  by  definite  fastigium,  with  crisis  or  defervescence,  and  a 
complete  restoration  of  the  patient  to  health. 

le)  The  finding  of  a  definite  microbe  in   the   blood,   tissues, 


3©  DIFFERENTIAL  DIAGNOSIS  chap. 

fluids,  or  excretions  of  the  patient.  Modern  discoveries  have 
made  this  an  almost  necessary  part  of  routine  clinical  study,  but  the 
microbe  must  be  put  through  the  above  strict  scientific  proof  before  its 
causative  role  will  be  accepted. 

Into  the  extraordinarily  fascinating  subject  of  attenuation  of 
microbes,  causes  of  immunity,  and  protective  and  curative  inocu- 
lations I  do  not  propose,  further  than  the  observations  recorded  on 
p.  31,  etc.,  to  enter.  The  work  that  has  been  done  in  this  direction 
would  fill  many  libraries  were  it  all  published,  but  it  is  entirely 
founded  on  the  above  principles. 

We  will  now  proceed  to  consider  the  differential  diagnosis  of 
the  ordinary  zymotic  diseases  of  England. 

For  the  student  to  attempt  to  learn  by  rote  the  apparently 
chaotic  variations  in  the  incubation  periods,  symptoms,  compHca- 
tions,  and  sequelae  of  these  diseases  seems  to  me  a  useless,  difficult, 
and  never-ending  task,  but  to  give  a  working  hypothesis  as  to  the 
essential  causes  of  these  discrepancies  and  variations  is  a  compara- 
tively simple  matter,  bringing  rule  and  order  out  of  confusion.  I 
say  hypothesis  advisedly,  because  though  we  have  every  reason  to 
believe  that  incidents  occur  in  the  body  in  precisely  the  same 
potential  sequence  as  in  the  test  tube,  we  have  no  absolute  proof 
that  they  do  so.  In  the  test  tube  there  is  no  variation  from  hour 
to  hour  in  the  bulk  and  quality  of  the  cultivation  menstruum, 
except  such  as  are  brought  about  by  the  mixture  of  bacterial  pro- 
ducts ;  there  are  no  policemen  leucocytes  exercising  their  unceasing 
vigilance  in  getting  rid  of  foreign  substances ;  it  is  doubtful  how 
far  these  cells  and  the  renewal  of  the  menstruum  can  fundamentally 
change  the  phenomena,  apart  from  their  undoubted  power  to  hinder, 
delay,  or  prevent  them  altogether. 

So  far,  then,  as  science  has  allowed  us  to  follow  the  workings  of 
microbes,  we  are  scarcely  using  the  language  of  metaphor  or  analogy 
when  we  speak  of  the  invasion  of  the  body  by  specific  germs 
in  precisely  the  same  terms  as  we  use  when  describing  the  invasion 
of  a  geographical  country  by  a  hostile  nation ;  the  differences 
between  the  engaging  forces  are  almost  nothing  but  those  of  size 
and  the  nature  of  the  weapons  used. 

The  first  event,  then,  is  an  attempted  landing  of  the  invading 
forces.  To  say  that  the  expedition  may  be  wrecked  by  storms  on 
sea  or  land  is  nothing  more  than  to  say  that  multitudes  of  malignant 
and  pathogenic  microbes  enter  the  apertures  of  the  body  or  alight 
on  the  skin,  but  are  immediately  swept  away  by  the  forces  of  respira- 
tion (sneezing,  coughing,  etc.),  by  food  and  drink,  by  smoking,  by 


Ill      MICRO-ORGANISMS  AND  ZYMOTIC  DISEASES       31 


accidental  rubbing  of  clothes,  by  washing,  etc.  ;  that,  in  fact,  they 
never  get  a  foothold  in  the  tissues  or  blood. 


Date  of  infection. 


Incubation  period. 


Reason  why  in  an 
epidemic  all  ex- 
posed do  not 
sicken  ;  meaning 
of  immunity  ;  ab- 
ortive cases  also. 


Malaise    of   incuba- 
tion period. 


Onset     sudden 
gradual. 


or 


Ingravescence  of  dis- 
ease and  fasti- 
gium. 

Defervescence,  or 
crisis,  or  death. 

Convalescence  and 
death  from  ex- 
haustion in  it. 


A  successful  landing  is  the  moment  of  infection, 
and  from  now  onwards  we  have  the  varying 
incidents  of  a  campaign. 

The  invaders  have  to  strengthen  their  position, 
increase  their  numbers  (for  our  story  it  is  im- 
material that  they  do  this  with  inconceivable 
rapidity  by  reproduction),  and  provide  food  ;  the 
time  thus  occupied  represents  the  incubation 
period. 

Even  now,  or  at  a  somewhat  later  stage,  when 
the  march  through  the  country  has  begun 
(abortive  cases),  a  complete  miscarriage  of 
the  whole  expedition  may  occur  through  (a)  a 
want  of  suitable  food  in  the  district,  or  {b)  the 
energy  of  the  local  inhabitants  and  first  line 
of  home  defences,  who  may  annihilate  the  in- 
vaders as  soon  as  they  emerge  from  their  local 
camp.  It  is  possible  in  either  or  both  of  these 
ways  to  explain  immunity,  natural  or  acquired, 
permanent  or  temporary  only. 

The  slight  excitement  caused  by  the  rumours  of 
an  invasion  represent  the  malaise  and  slight 
symptoms  of  the  incubation  period. 

The  relative  strengths  of  the  contending  parties 
explain  the  nature  of  the  onset.  In  one  set 
the  invaders  are  so  powerful,  or  have  become 
so  numerous,  that  their  attack  and  onward 
march  cause  the  utmost  consternation  through- 
out the  land  ;  in  the  other  they  are  so  insigni- 
ficant in  strength  or  numbers  that  only  a  slight 
disturbance  is  caused  at  first,  though  later 
their  power  may  be  enormously  increased  by 
reinforcements,  etc. 

As  the  invaders  march  through  the  country  the 
war  rages  with  increasing  violence,  until  either, 
in  repeated  conflicts,  or  in  one  great  pitched 
battle,  the  invaders  are  destroyed,  or  per  contra, 
the  defenders  are  completely  defeated. 

When  the  invaders  have  been  thoroughly  routed 
comes  the  time  for  rebuilding  cities,  towns, 
and  villages,  and  for  recuperation  of  the  in- 
habitants, and  it  may  happen  that  the   whole 


32 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Persistent  debility, 
or  even  stronger 
than  ever. 

Complications  and 
sequelae. 

(i)  Specific  to  the 
disease,  e.g.  otor- 
rhcea. 

(2)  A  second  specific 
disease  succeed- 
ing the  first. 


(3)  Non  -  specific 
complications,  e.g. 
abscesses  from 
pyogenes,  coli 
commune,  etc. 


nation  is  so  exhausted  that  this  is  impossible, 

and  life  ceases  in  the  country. 
Rebuilding  and  renovation  may  remain  for  ever 

incomplete,   or  may  be   such  as  to  make  the 

country  stronger  than  before. 
In   such  a  war  of  invasion  there  may  be  found 

three  well-marked  classes  of  events  : — 
(i)  The   attacks    on  the  principal   cities  by  the 

original  invaders. 

(2)  A  separate  descent  upon  the  country  of  a 
different  invading  force,  which,  eating  different 
food,  or  fighting  with  different  weapons,  may 
go  through  all  the  vicissitudes  of  the  first 
force. 

(3)  Turbulence  and  riot  on  the  part  of  a  mal- 
content native  or  alien  population  which  had 
previously,  under  pressure  from  local  authority, 
lived  more  or  less  quiet,  and  even  useful,  lives. 


Dropping  now  the  possible  suspicion  of  using  metaphorical 
language,  we  know  for  a  certainty  we  have  the  following  variables 
in  every  equation  of  infectious  disease : — 

1.  The  inherent  constitution  of  the  individual's  tissues,  cells 
and  body  fluids,  including  the  presence  or  absence  of  certain 
materials  for  the  growth  of  microbes,  the  power  of  manufacturing 
antitoxin,  or  of  eating  up  these  microbes. 

2.  The  quasi-accidental  temporary  powers  of  the  same  at  the 
time  of  infection. 

3  and  4.   Similar  powers  on  the  part  of  the  invading  microbes. 

5.  The  actual  number  of  the  latter  gaining  admission  (antago- 
nism between  different  microbes  landing  at  the  same  time). 

Scientific  laboratory  work  has  proved  beyond  all  doubt  that 
each  of  these  is  of  the  utmost  degree  of  importance,  but  it  has  not 
given  us  even  an  inkhng  as  to  the  laws  which  govern  the  variations 
on  the  part  of  the  body  forces,  and  is  only  on  the  threshold  of  in- 
vestigations into  those  regulating  the  microbes  ;  the  strongest  men 
often  enough  fall  victims  to  epidemics  while  the  weakhngs  escape, 
some  in  contact  with  the  patients  are  smothered  with  microbes  and 
escape,  while  for  others  or  even  the  same  persons  at  another  time, 
a  single  contact  is  sufficient  to  produce  a  most  virulent  attack. 

Although  these  unknown  variables  and  their  unknown  laws  make 


Ill       MICRO-ORGANISMS  AND  ZYMOTIC  DISEASES       Z3 

any  tables  of  comparatively  little  scientific  value,  the  following 
may  be  found  of  some  practical  utility  in  clinical  work  as  well  as  for 
examination  purposes. 

Table  of  Incubation  Periods 


Anthrax   . 

> 

'   2  or  3  days. 

Cholera    . 

up  to  15  ,, 

Diphtheria 

Have    been    known    to 

2  to  4       ,, 

Influenza. 

develop  within  24  hours 

3  or  4       „ 

Pneumonia 

of  infection,  though  the 
annexed       periods      in 

Relapsing  fever 

4  to  10    ,, 

Scarlet  fever 

days      are     very    much 

2  to  5        „ 

Septiccemia 

commoner. 

Tetanus   . 

up  to   21    ,, 

Yellow  fever 

J 

.  up  to  18  ,, 

The  following,  arranged  roughly  in  ord^r  of  duration,  are  : — 

Gonorrhoea 

2  to     3  days.      Pertussis          .          .   6  to  1 2  days. 

Typhus  . 

2  to  12    ,,          Measles.          .          .   8  to  12    ,, 

Glanders 

3  to  18    ,,          Malta  fever      .          .   about  10,, 

Typhoid 

4  to  20    ,,          Rotheln  .          .          .    10  to  21  ,, 

Variola     . 

.    II  or  1 2  days  (curiously  constant). 

Varicella  . 

.    10  to  14     ,, 

Erysipelas 

.    10  to  14     „ 

Mumps     . 

.    12  to  21      „ 

Syphilis    . 

.    18  to  28     „ 

Rabies 

.   40  days  and  upwards 

Tubercle  . 

.   Unknown,  probably  . 
1       ,' t 1-j  1 

5ome  weeks. 

Our  previous  considerations  have  led  us  a  priori  to  expect  what 
we  actually  find,  viz.  that  the  variations  are  much  too  great  and 
too  irregular  to  serve  any  diagnostic  purpose ;  but  they  explain  why 
three  weeks  has  been  adopted  as  the  period  of  segregation  of 
individuals  who  have  been  exposed  to  infection,  where  such 
segregation  is  possible,  as  in  schools  and  pubUc  institutions. 

When  the  incubation  period  is  at  an  end,  and  the  actual  onset 
of  the  disease  begins,  diagnosis  rapidly  narrows  itself  down.  Many 
of  those  enumerated  above  show  characteristic  features,  apart  from 
pyrexia,  almost  at  once,  thus  : — 


Anthrax 
Cholera 


Ring  of  vesicles  with  central  black  slough. 
Characteristic   diarrhoea,   except  in  fulminat- 
ing cases. 
D 


34 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Diphtheria 
Pneumonia     . 

Wound-Septicaemia 

Gonorrhoea 

Syphilis     and      venereal 

poisons 
Glanders 
Erysipelas 

Tetanus 
Mumps 


Membrane  on  infected  spot. 

Cough  and  disturbance  of  respiratory  rhythm, 

vide  p.  35. 
Wound  inflamed  and  discharging. 
Urethral  trouble. 

A  chancre  of  some  description. 

Particularly  acrid  nasal  discharge. 

Sharply    defined    red    blush    surrounding    a 

wound. 
Stiffness  of  jaws,  or  abdominal  muscles. 
The  swelling  of  both  parotids. 


The  bulk  of  the  remainder  is  constituted  by  the  common  so- 
called  zymotic  diseases  or  exanthems  of  our  country.  In  them  the 
presence  of  an  epidemic  gives  the  primary  and  the  strongest  clue  to 
the  diagnosis.  I  might  go  so  far  as  to  say  that  in  many  aberrant 
and  abortive  cases  this  forms  the  only  guide,  for  without  it  many 
cases  of  sore  throat,  or  of  rashes  in  a  scarlet  fever  epidemic,  of 
nasal  catarrh  in  an  outbreak  of  measles  or  influenza,  would  go 
unrecognised.  Next  to  epidemicity,  the  manner  of  onset  in  fairly 
typical  cases  gives  the  best  clue  to  differential  diagnosis.  Thus 
they  are  all  accompanied  with  pyrexia,  which  in  — 


Influenza 
Relapsing  fever 
Scarlet  fever 
Typhus 
Variola 

Measles 
Pertussis 
Rotheln 
Typhoid 


Almost  invariably  comes  on  very  rapidly, 
reaching  its  probable  maximum  within 
twenty-four  hours. 


Comes  on  much  less  rapidly,  taking  two 
or  three  days  or  even  longer  (especially  in 
typhoid)  to  reach  its  height. 


After  the  onset  a  period  elapses,  nearly  constant  for  each 
zymotic,  before  the  further  diagnostic  point  of  the  characteristic  rash 
is  available.  We  may  utilise  this  period  to  draw  attention  to  those 
symptoms  which,  if  not  actually  the  result  of  a  temperature  above  the 
normal  (a  point  made  doubtful  by  many  considerations),  are  at  any  rate 
the  twin  results  with  pyrexia  of  the  toxaemias  of  disease.  They  are 
very  important,  as,  when  they  are  present,  they  suggest  the  continual 
use  of  the  clinical  thermometer;  they  also  give  the  student  a 
rational  and  firm  basis  for  a  written  description  of  the  symptoms  of  any 


Ill       MICRO-ORGANISMS  AND  ZYMOTIC  DISEASES       35 

zymotic,  of  which  indeed,  ^^^th  the  rash,  they  form  the  bulk,  stress 
being  only  laid  on  special  points. 

Following  the  plan  laid  down  on  p.  2,  we  have : — 

The  Symptoms  of  Pyrexia 


Tongue. 

Appetite. 

Thirst. 
Bowels. 

Respiratory  and 
vascular 
symptoms. 


Urinary  system. 


SkiiL 


Alitnentar)'  System 

Usually  a  tendency  to  get  dry  and  dirty,  in 
typhoid  and  in  scarlet  fever  often  typical. 

Much  diminished,  probably  digestion  is  nearly  in 
abeyance. 

Almost  constantly  increased. 

Constipation  the  rule,  in  measles  and  typhoid 
diarrhoea  not  uncommon. 

The  respiration  and  pulse  are  quickened,  and  in 
simple  case  in  their  ordinary  ratio  of  i  to 
2-5-.  It  is  a  sufficiently  accurate  and  good 
clinical  rule  to  expect  an  increase  of  about  10 
beats  per  minute  in  the  pulse  rate  for  each 
degree  F.  that  the  temperature  is  over  the 
normal.  The  principal  exceptions  are  scarlet 
fever,  in  which  the  pulse  rate  is  often  acceler- 
ated out  of  all  proportion,  and  influenza,  in 
which  there  is  very  little  acceleration.  If  the 
ratio  of  2^  to  i  is  markedly  altered,  pulmonary 
or  cardiac  (endo-  myo-  or  peri-cardial)  compli- 
cations must  be  strongly  suspected  and  care- 
fully looked  for. 

The  urine  is  usually  diminished  in  quantity, 
increased  in  colour  and  specific  gravity  ;  urates 
are  very  frequently  deposited  in  excess  on 
cooling.  There  seems  to  be  no  doubt  that  the 
toxins  of  all  diseases  are  irritating  to  the 
kidney  (by  which  channel  they  are  largely 
excreted),  hence  the  presence  of  a  trace  of 
albumen  is  very  common  ;  it  has  little  signifi- 
cance either  as  a  signal  of  future  kidney  dis- 
ease, or  as  a  diagnostic  point,  except  in  scarlet 
fever,  where  obstinate  nephritis  is  an  only  too 
frequent  sequela,  and  in  diphtheria,  when 
albuminuria  helps  to  decide  the  nature  of  an 
otherwise  doubtful  sore  throat. 

Is  often  hot  and  dry,  or  may  be  moist  and 
covered  with  sudamina. 


36  DIFFERENTIAL  DIAGNOSIS  chap. 

Nervous  system.  Headache,   especially  at  back  of  eyes,  a  feeling 

of  languor  and  debility  with  aching  sensations 
in  the  limbs  and  back  more  or  less  severe, 
and  the  consequent  restlessness,  are  all  that 
can  be  ascribed  to  ordinary  pyrexia  ;  should 
the  temperature  be  over  105°  delirium  or 
coma  may  supervene,  but  these,  with  subsultus 
tendinum,  floccitatio,  etc.,  belong  much  more 
to  poisoned  than  to  heated  blood,  and  may  be 
seen  with  a  subnormal  temperature.  It  is 
worth  while  to  note  that  small-pox,  even 
in  comparatively  mild  cases,  is  associated 
with  a  back  -  ache  of  quite  disproportionate 
severity. 

The  characteristic  rash  of  each  disease  now  begins  to  appear, 
almost  constantly  as  in  the  table  below.  With  its  appearance, 
though  probably  long  before,  the  diagnosis  will  be  complete. 

Such  are  the  usual  features  of  the  rashes  of  our  zymotics,  and 
they  will,  if  anything  like  typical,  be  found  sufficient  to  finally  clinch 
a  diagnosis  which  even  for  the  most  experienced  may  have  remained 
doubtful  previous  to  the  appearance  of  the  rash. 

Desquamation. — Inasmuch  as  desquamation  is  usually  considered 
very  strong  if  not  conclusive  evidence  in  favour  of  a  past  infectious 
disease,  it  may  not  be  out  of  place  to  state  definitely  once  for  all 
that  it  may  be  seen  of  almost  any  degree  and  character  in  patients 
who  have  been  in  bed  for  any  disease.  It  is  extremely  copious  in 
the  course  of  some  skin  affections  (dermatites),  also  after  excessive 
doses  of  thyroid  gland,  and  after  prolonged  (some  days)  bathing,  as 
in  typhoid ;  but  I  have  also  seen  it  after  pneumonia,  in  the  course 
of  kidney  disease,  as  well  as  in  patients  affected  with  chronic  spinal 
cord  mischief. 

We  have  now  concluded  the  symptomatological  diagnosis  of  our 
infectious  diseases  ;  it  simply  remains  to  tabulate  a  few  of  the 
most  salient  features  of  contrast  of  the  individual  affections  which 
are  likely  to  be  confounded,  or  which  are  of  special  interest  to 
students. 


[Table 


Ill       MICRO-ORGANISMS  AND  ZYMOTIC  DISEASES       37 


Table  referred  to  on  page  36 


Disease. 

Date  of  Rash  after 
Onset. 

Locality. 

Characters. 

Varicella 

Within  24  hours 

Anywhere,          fre- 

Clear    vesicles,     not 

quently      several 

umbilicated,        but 

crops  of  them. 

they  often  leave 
scars. 

Scarlet 

Within  48  hours 

Chest  first,  rapidly 

Bright,  boiled-lobster 

fever 

spreads  to  trunk, 

colour,      disappears 

face,  and  limbs. 

on  pressure  (except 
in  malignant  cases), 
followed  by  large 
flaky  desquama- 
tion, which  con- 
tinues longest  on 
hands  and  feet. 

Rotheln.i 

About  3rd  day 

Trunk 

Mottled  like  measles, 
or  red  like  scarlet 
fever,  followed  by 
small  branny  des- 
quamation. 

Variola 

3rd  day 

Forehead  first,  but 

At    first    felt    rather 

soon  nearly  uni- 

than seen  as  a  soft. 

versal  ;   only  one 

velvety     feeling    of 

crop,  V.  varicella 

skin  with  nodules 
under  it ;  soon  um- 
bilicated vesicles, 
becoming  pustules 
in  4  or  5  days,  and 
almost  invariably 
leaving  scars. 

Measles 

4th  day 

Forehead          first, 

Mottled,  patchy,  does 

and   limbs,    soon 

not  absolutely    dis- 

spreads to  trunk 

appear  on  pressure. 
Desquamation  is 
small  and  branny. 

Typhus 

5th  day 

Wrists  very  early, 

Mottled  and   ha^mor- 

soon      universal. 

rhagic  spots,  not  dis- 

One crop  only. 

appearing  on  pres- 
sure, conspicuous. 

Typhoid 

7  th  or  8th  day 

Abdomen  and  back, 

Small     red,     slightly 

successive  crops 

elevated  spots,  dis- 
appearing on  pres- 
sure, and  usually 
want  looking  for. 

^  There  is  some  dispute  as  to  the  existence  of  this  disease  ;  its  clinical  features,  as 
allowed  by  the  believers  in  it,  are  exactly  intermediate  between  scarlet  fever  and 
measles. 


SS  DIFFERENTIAL  DIAGNOSIS  chap. 


VARICELLA       v.  VARIOLA 

Fever    and     constitu-     Scarcely  marked,  and     Usually     very     severe, 
tional  symptoms.  even       if      pyrexia  and     especially     the 

severe,      still      not  back-ache, 

much  constitutional 
disturbance. 
Date  of  rash.  First  day.  Anything   in    first    two 

days  will  be  prelimi- 
nary atypical  and 
probably  hsemor- 
rhagic  ;  typical  rash 
on  third  day. 
Rash  itself.  Often  successive  crops,     Always  one  crop  only. 

non   -    umbilicated,  Umbilicated         and 

hemispherical;  often  confluent, 

practically        never 

confluent ;  contents     Contents  always   puru- 
rarely     more     than  lent ;     forehead     al- 

milky ;  appear  any-  most      always       the 

where.  first. 

It  is  but  very  rarely  that  any  serious  difficulty  arises  in  the 
differential  diagnosis  of  these  two  diseases,  only  an  extraordinarily 
severe  case  of  varicella  could  be  mistaken  for  a  mild  attack  of 
modified  variola  and  m'ce  versa.  It  is  well  to  emphasise  the  fact 
(usually  unnoticed  or  denied)  that  varicella  does  frequently  leave 
pitted  scars  which  may  easily  be  mistaken  individually  for  those  left 
by  smallpox,  their  greater  number  after  the  latter  will  be  the  best 
guide. 

VARIOLA  V.  SYPHILIS 

A  far  more  difficult  problem  may  occasionally  arise  to  decide 
between  the  rash  of  variola  and  a  varioliform  syphilide.  In  both, 
the  fever  and  constitutional  symptoms  may  be  very  severe,  and  the 
actual  spots  may  be  identical  in  appearance,  umbilicated  and  puru- 
lent. The  most  reliable  point  will  be  the  situation  of  the  rash, 
which  in  syphilis  is  nearly  sure  to  be  confined  to  the  forehead,  where 
it  may  be  very  copious ;  it  is  almost  certain  to  be  much  more  widely 
spread  in  variola.  If  doubt  remains,  a  history  of  a  chancre  must  be 
sought,  and  may  clear  up  the  diagnosis. 


Ill      MICRO-ORGANISMS  AND  ZYMOTIC  DISEASES      39 


DIPHTHERIA  v.   "HOSPITAL,"  OR   "ULCERATED' 
SORE  THROAT 

The  following  points  are  usually  made  in  separating  these 
troubles : — 

Diphtheria.  Ulcerated  Sore  Throat. 

Always    derived   from    a    previous      May  arise  de  novo  (at  least  with- 
case.  out  known  exposure  to  previous 

throat     case),     from     smell     of 
drains,  septic  wounds,  etc. 
Temperature  not   high   as   a   rule,      Temperature  higher,  on  an  average 

102°  maximum.  101°  to  105°. 

False  membrane  includes  necrosed     False  membrane  only  an  exudate, 
epithelium,   if  removed  leaves  a  if   removed    does    not    leave    a 

bleeding  raw  surface.  bleeding  surface. 

Albuminuria.  No  albumen  in  urine. 

Knee  jerks  often  lost,  and  neuritis     No  loss   of  knee  jerk  or  neuritic 

as  sequela.  sequela. 

Klebs-Loeffler  bacillus  found.  Other  microbes  but  not  the  Klebs- 

Loeffler. 

Notwithstanding  the  discovery  of  the  Klebs-Loeffler  bacillus, 
which  must  be  by  all  admitted  as  the  only  cause  of  one  specific 
form  of  disease  called  by  the  name  of  diphtheria,  I  am  strongly 
convinced,  as  the  result  of  personal  experience,  that  there  are 
several  kinds  of  microbes  which  can  give  rise  to  forms  of  ulcerated 
sore  throat,  which  by  every  clinical  test  are  indistinguishable  from 
the  diphtheria  produced  by  the  Klebs-Loeffler  bacillus ;  there  may 
be  sloughing  and  bleeding  on  removal  of  the  slough,  there  may  be 
albuminuria,  and  possibly  disturbance  of  function  of  peripheral 
nerves — in  fact,  everything. 

This  statement  may  be  accepted  without  its  being  held  that  I 
am  preaching  a  dangerous  doctrine,  for  I  hold  that  the  same  care 
should  be  given  to  every  case  of  ulcerated  throat,  and  that  the 
same  isolation,  especially  as  regards  kissing  and  breathing  the 
breath  of  the  patient,  should  be  practised,  whatever  the  microbe 
may  be,  for  all  such  cases  are  undoubtedly  infectious.  Nor  do  I  dis- 
approve of  the  use  of  antitoxin.  I  hold  very  strongly  that  if  the 
throat  be  due  to  the  Klebs-Loeffler  bacillus,  the  injections  will 
cure,  when  the  case  without  them  would  be  hopeless ;  and  if  the 


40 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


throat  be  due  to  other  microbes,  the  injections  will  certainly  do  no 
harm. 

It  may  be  that  the  acceptance  of  my  view  tends  to  vitiate  the 
statistics  of  diphtheria,  and  hence  those  of  antitoxin  cures.  This 
I  cannot  help,  for  I  believe  I  am  stating  truth,  and  that  even  the 
most  experienced  will  admit  it.  The  confusion  —  if  confusion 
there  be — is  due  to  the  fact  that  we  do  not  yet  know  all  the 
powers  for  evil  of  all  microbes,  nor  the  laws  which  govern  their 
growth  on  human  tissues,  and  the  powers  of  resistance  of  these 
same  tissues. 

We  have  already  noted  that  rotheln  as  a  distinct  disease  is 
not  recognised  by  some  observers.  Accepting  its  existence,  how- 
ever, the  following  table,  constructed  from  Dr.  Roberts'  Medicine^ 
shows  the  principal  characters  of  the  three  diseases  —  rotheln, 
measles,  and  scarlet  fever — their  likenesses  and  contrasts : — 


MEASLES 


ROTHELN 


SCARLET  FEVER 


Eight  to  twelve  days, 
never  a  few  hours 
only. 


Incubation 

Ten  to  twenty  days, 
never  a  few  hours 
only. 


Two  to  five  days, 
often  within  twenty- 
four  hours. 


Fairly     sudden,     with 
rapid  increment. 


Onset 

Sudden,    but    gets   no     Very  sudden,  acme  in 
worse.  twelve  hours  or  so. 


Symptoms  of  Onset 

Catarrh   of  nose    and     Sore    throat,    but    not     Throat  symptoms  very 
eyes.  so    bad    as     scarlet  prominent, 

fever. 


About  102°. 


Temperature 
102°  or  lower. 


102°  or  higher. 


Appears  about  fourth 
day,  distinctly  to  be 
felt,mottled  patches, 


Rash 

Appears  second  day, 
papules  brighter 
than  in  measles  but 


Appears  in  twenty-four 
hours,  not  raised  nor 
to    be     felt,     large 


Ill      MICRO-ORGANISMS  AND  ZYMOTIC  DISEASES      41 


does  not  completely 
disappear  on  pres- 
sure, symptoms  soon 
lessen  when  rash 
appears,  rash  lasts 
three  or  four  days. 


Proportional  to  fever. 


patchy,  may  coal- 
esce and  be  bright 
like  scarlet  fever. 
Symptoms  nearly 
gone  when  rash  ap- 
pears, rash  lasts  al- 
ways four  or  five 
days,  and  may  be 
eight  or  ten,  longer 
than  either  of  the 
other  two. 

Pulse 
Proportional  to  fever. 


areas,  uniformly 
bright  red  ;  disap- 
pears entirely  on 
pressure;  symptoms 
worse  if  anything 
when  rash  is  at  its 
height ;  rash  lasts 
four  or  five  days. 


Frequent,    out   of  pro- 
portion to  fever. 


Varieties  (only  to  be  noted  in  Epidemics) 
Sine     eruptione,     sine     No   marked   varieties,      Sine    eruptione,    angi- 


catarrho,  malignant 
(haemorrhagic). 


but    may    occasion- 
ally be  rather  severe. 


nosa  (throat  speci- 
ally bad),  maligna 
(haemorrhagic). 


Sequels  and  Complications 


Eyes,   nose,  and  ears.      None     usually ;     very     Nephritis  and  dropsy, 
but    especially    cat-  rarely  nephritis.  rheumatism,  ear  dis- 

ease, endocarditis, 
cellulitis  of  neck, 
cancrum  oris,  ab- 
scesses. 


arrh  of  air  passages, 
also  catarrh  of  in- 
testinal tract.     Can- 


crum oris. 


Without  the  rash  and  without  the  presence  of  an  epidemic  to 
guide  one,  there  are  no  features  that  will  enable  a  diagnosis  to  be 
made  between  some  cases  of  bad  sore  throat  and  the  throat  which 
may  accompany  either  scarlet  fever  or  (occasionally)  measles. 

Quite  recently  there  have  been  described  small  whitish  spots 
on  the  mucous  membrane  of  the  mouth  and  palate,  which  are  said 
to  be  a  pathognomonic  indication  of  incipient  measles. 

TYPHOID  V.   TYPHUS 


Typhus. 
I.    Only    seen     in     crowded     poor 
communities ;     almost     absolute 
contact  required  for  infection. 


Typhoid. 
I,    Epidemics  common  in  sparsely 
populated  districts,  conveyed  by 
milk  or  water  to  a  distance. 


42 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Typhus. 

2.  Incubation,  two  to  twelve  dayi. 

3.  Onset  very  sudden. 

4.  Symptoms  markedly  nervous 
and  cerebral. 

5.  Rash  prominent  to  eye,  as 
much  on  limbs  as  body,  usually 
hsemorrhagic,  appears  earlier 
than  in  typhoid,  five  or  six 
days. 

6.  Constipation  the  rule. 

7.  Crisis  almost  invariable  ending. 

8.  Complications  septic  in  charac- 
ter anywhere  in  the  whole  body. 


9.   No  characteristic   lesions  after 
death. 


6. 


7. 


Typhoid. 

Very  indefinite,  may  be  a  fort- 
night or  more. 

Onset  usually  insidious,  but  may 
be  rather  sudden. 

Symptoms  markedly  gastro-in- 
testinal,  though  headache  often 
severe. 

Rash  usually  requires  to  be 
looked  for  ;  almost  confined  to 
trunk ;  rarely  more  than  ery- 
thematous spots,  entirely  dis- 
appearing on  pressure,  rarely 
present  in  first  week. 

Diarrhoea  the  rule,  at  any  rate 
in  second  week. 

Lysis  almost  invariable  ending. 

Chief  complications  abdominal, 
—  perforation,  peritonitis,  or 
haemorrhage,  but  periosteal  ab- 
scesses not  very  uncommon. 

Characteristic  lesions  of  intes- 
tines. 


Considering  the  absolute  contrasts  that  these  two  diseases 
offer,  it  would  seem  impossible  that  they  should  have  been  so  long 
confounded ;  but  we  must  remember  that  in  those  days  typhus  was 
very  much  more  common  than  now,  and  therefore  there  were 
probably  many  cases  aberrant  from  the  type.  If  we  remember, 
too,  that  what  is  now  known  as  the  "  typhoid  state  "  (dry,  brown 
tongue,  delirium,  subsultus  tendinum,  and  collapse)  is  the  charac- 
teristic condition  of  any  severe  blood-poisoning  of  any  nature,  we 
may  cease  to  wonder  at  the  confusion. 

The  separation  of  the  two  is  now  of  almost  purely  academic 
examinational  (and  historical)  interest,  for  typhus  is  so  rare  that 
scarcely  i  per  cent  of  medical  men  ever  see  a  case. 

The  above  table  is  quite  sufficient  should  the  differential 
diagnosis  be  required. 

Weidal's  test  (the  influence  of  the  serum  of  a  suspected  person 
upon  cultivations  of  typhoid  bacilli)  has  recently  been  discovered. 
Its  reliabihty  would  up  to  date  seem  to  be  of  the  very  highest 
degree,  in  fact  almost  absolute  if  done  by  a  skilled  bacteriologist. 


Ill       MICRO-ORGANISMS  AND  ZYMOTIC  DISEASES       43 

CHOLERA  ASIATICA  v,  CHOLERA  NOSTRAS  (Severe 
Diarrhcea  or  Ptomaine  Poisoning) 

In  England,  luckily,  we  are  not  often  called  upon  to  deal  with 
an  epidemic  of  true  Asiatic  cholera ;  but,  frequently  enough,  it  is 
imported  into  our  seaports,  and  occurs  sporadically  from  this 
origin,  so  that  the  diagnosis  is  of  some  importance. 

The  essential  etiological  pathology  of  all  such  intestinal  fluxes 
is  the  same.  An  irritant  reaches  the  intestinal  canal  and  causes  a 
severe  diarrhoea,  to  which,  in  the  main,  and  not  to  the  specific 
nature  of  the  irritant,  the  symptoms  are  due.  The  diagnosis  must 
then  eventually  rest  upon  the  scientific  discovery  or  proved  absence 
of  the  comma  bacillus  of  cholera,  but  the  following  clinical  points 
are  worth  bearing  in  mind  : — 

1.  If  the  outbreak  or  case  be  due  to  some  ordinary  irritant 
(chemical  or  living)  in  the  food  there  will  usually  be  an  obvious 
history  of  such  being  the  case,  e.g,  a.  public  dinner,  or  all  the  mem- 
bers of  a  family  being  simultaneously  attacked  after  a  meal. 

2.  Children  are  almost  the  exclusive  sufferers  from  our  summer 
diarrhoea.  If  adults  are  also  attacked,  then  paragraph  (i)  is 
nearly  sure  to  be  true. 

3.  In  food-poisoning  cases  all  the  patients  will  be  attacked  so 
nearly  simultaneously  or  under  such  circumstances  as  to  exclude 
the  possibility  of  infection  from  patient  to  patient. 

4.  Cholera  nostras  occurs  with  us  almost  exclusively  in  very 
hot  summer  weather,  or  in  the  autumn,  when  there  is  much  spoiled 
fruit  about. 

5.  Rice  water  stools  are  said  to  be  very  typical  of  true  cholera. 
They  are  seldom  passed  by  patients  \\dth  ptomaine  poisoning. 

6.  In  a  fatal  case,  with  none  of  the  above  guiding  indications, 
bacteriology  must  be  called  upon  for  the  diagnosis. 

ERYTHEMA  SIMPLEX  v.  OTHER  RASHES 

To  separate  simple  erythema  from  the  er}nhematous  rashes  of 
more  serious  disease  is  a  problem  rather  frequently  arising  in 
children.  A  new  blanket,  or  underclothing  of  wool,  a  little  dys- 
pepsia, \nll  frequently  produce  a  rash  closely  resembling  that  of 
scarlet  fever  or  erysipelas.  In  all  cases  of  the  slightest  doubt  an 
appeal  must  be  at  once  made  to  the  clinical  thermometer,  and  again 
in  twelve  hours  or  so.     Two  or  three  observations  on  the  tempera- 


44  DIFFERENTIAL  DIAGNOSIS  chap. 

ture  will  clear  up  most  cases.  There  is  seldom  pyrexia,  at  any  rate 
of  more  than  a  few  hours'  duration,  with  the  simpler  troubles,  and 
still  less  frequently  an  apyrexial  condition  when  infectious  disease  is 
the  cause  of  the  rash.  Besides  the  temperature  the  following 
points  will  be  of  assistance  :- — 

Erythema.  Erysipelas,  etc. 

Margin  of  rash  gradually  fades  into     Outline    of    blush    very    distinct. 

healthy  colour.    Locality  erratic,  Locality  usually  recognisable  as 

no  discoverable  wound.  that  of  a  specific  fever,  or  round 

a  wound. 
No       constitutional       disturbance.      Usually    considerable    disturbance 

headache,  vomiting,  or  chilliness.  of  bodily  health. 

Probable  history  of  some   contact     Probable  suspicion  of  infection. 

with  irritating  clothing  material 

or  known  slight  trouble. 
Little  tendency  to  spread  after  once     Usually    spreads    distinctly    under 

it  is  out  and  discovered.  observation,  while  symptoms  re- 

main or  get  worse. 


INFLUENZA 

Of  late  years  we  have  had  a  repeatedly  recurring  recrudescence 
of  this  pest,  and  many  opportunities  for  estabHshing  its  differential 
diagnosis.  In  the  several  epidemics  it  has  almost  seemed  as 
though  we  had  as  many  separate  diseases  to  deal  with — now  an 
outbreak  of  contagious  meningitis,  now  a  pulmonary  epidemic,  and 
now  one  of  gastro-intestinal  catarrh  or  worse.  In  some  a  severe 
catarrh  of  the  nose  and  eyes  with  a  mottled  rash  has  aroused  suspi- 
cion of  measles,  while  in  others  a  severe  tonsilHtis  and  a  bright  red 
rash  have  made  a  diagnosis  of  scarlet  fever  seem  almost  justified. 

The  view  which  seems  to  me  to  best  explain  these  vagaries  is  to 
assume  that  the  microbe  of  influenza  (it  has  not  yet  been  isolated 
to  the  satisfaction  and  acceptance  of  everybody,  though  its  existence 
is  universally  believed  in)  has  but  little  specificity  of  its  own.  If  it 
has  a  particular  affinity  it  is  for  the  nervous  system,  which  it  attacks 
with  undue  violence,  causing  disproportionate  headache  and  pains, 
and  followed  by  a  debiUty  out  of  all  proportion  to  its  pyrexia. 
Should  the  victim  of  its  attack  possess,  however,  a  distinct  locus 
mi?tons  resistentiae  it  will  attack  that  locus,  and  cause  what  is 
apparently  a  simple  non-specific  inflammatory  attack,  a  pneumonia, 
a  nephritis,  a  tonsilHtis,  a  diarrhoea,  etc. 


Ill      MICRO-ORGANISMS  AND  ZYMOTIC  DISEASES      45 

As  regards  its  actual  diagnosis,  my  own  experience  would  lead 
me  to  say  that  in  cases  uncomplicated  by  any  actual  inflammatory 
disease  of  an  organ  its  main  characteristics  are  : — 

1.  The  absolute  suddenness  (even  to  the  minute)  of  the  onset 
of  malaise  and  chilliness. 

2.  The  presence  of  pyrexia,  above  99.5  say,  separates  it  from 
an  ordinary  cold  in  the  head,  especially  in  conjunction  with — 

3.  The  great  intensity  of  the  aching  in  the  limbs  and  eyes. 

4.  During  the  first  twenty-four  to  forty-eight  hours  the  diag- 
nosis, at  least  in  children,  must  remain  in  doubt  if  any  other 
epidemic  is  about. 

5.  At  the  end  of  this  period,  when  we  are  expecting  a  rash  or 
some  other  specific  symptom,  the  temperature  falls,  and  the  patient 
is  convalescent,  unless  some  definite  complication  has  occurred. 

6.  If  such  a  local  affection  arise,  the  fact  that  it  is  due  to  in- 
fluenza can  only  be  determined  by  the  prodromal  symptoms  which 
are  absent  in  the  simple  cases. 

In  those  cases  where  a  rash  and  coryza  or  tonsillitis  occur  a 
certain  and  unquestionable  diagnosis  is  at  first  impossible,  unless 
there  be  a  definite  epidemic  of  influenza  in  the  air,  but  we  may 
remember : — 

{a)  The  rash  is  more  evanescent  in  influenza  than  in  scarlet 
fever  or  measles. 

{b)  The  whole  febrile  period  without  complications  is  also  much 
shorter. 

if)  Scarlet  fever  and  measles  but  seldom  occur  more  than  once 
in  a  lifetime,  and  therefore  a  previous  history  of  either  is  pro  tanto 
a  point  in  favour  of  influenza. 

{d)  Just  the  reverse  holds  of  influenza,  and  a  previous  attack 
makes  the  present  one  more  probably  of  that  nature. 

{e)  In  adults  first  attacks  of  scarlet  fever  and  measles  are  com- 
parative rarities,  while  influenza  mayhave  its  first  incidence  at  any  age. 

VENEREAL  INFECTIOUS  DISEASES 

These  include  gonorrhoea,  syphilis,  and  septic  inoculations. 

The  diagnosis  of  gonorrhoea,  with  its  special  power  of  producing 
a  suppurative  discharge  from  mucous  membranes,  need  not  delay 
us.  It  is  the  truthfulness  of  the  history  more  than  the  nature  of 
the  urethritis  that  requires  consideration. 

To  differentiate  a  simply  septic  venereal  sore  from  a  true 
syphilitic  chancre  is   much   more  difficult,   and   the   fact  that  the 


46 


DIFFERENTIAL  DIAGNOSIS 


CHAP.  Ill 


syphilitic  and  septic  microbes  are,  with  extraordinary  frequency, 
inoculated  together  and  grow  side  by  side  renders  it  often  impos- 
sible to  tell  whether  a  given  sore  will  ultimately  prove  syphilitic  or 
not.  Remembering,  then,  that  many  sores  are  both,  the  following 
points  must  be  taken  only  as  guides,  not  as  infallible  supports : — 


Septic. 
Incubation  only  a  day  or  two. 


Suppuration    ana  ulceration   fairly 
free. 


Frequently  multiple,  and  can  be 
inoculated  on  to  a  separate  part 
of  the  body  intentionally  or  acci- 
dentally. 

Induration,  if  present,  fades  off 
gradually,  and  is  only  inflam- 
matory oedema. 

Bubos  often  form,  enlarge,  soften, 
and  abscess  forms. 

No  rash,  sore  throat,  or  other  con- 
stitutional disturbance  at  a  later 
period. 


Syphilitic. 

Some  three  weeks.  A  sore  (the  date 
of  inoculation  for  which  can  be 
sworn  to)  cannot  be  purely  syphi- 
litic if  it  appears  within  a  week, 
but  it  may  be  both. 

Pure  syphilis  does  not  suppurate, 
and  probably  not  ulcerate ;  but 
if  a  sore  does  ulcerate  and 
become  phagaedenic,  it  is  curious 
that  it  almost  always  contains 
also  the  syphilitic  virus. 

Most  usually  single,  and  cannot  be 
inoculated  on  to  a  distant  part 
of  the  body. 

Induration  is  sharply  defined  like  a 
wad  let  into  the  skin.  Is  some- 
thing special  to  syphilis,  not 
simple  inflammatory. 

Bubos  are  hard  and  isolated,  and 
if  due  purely  to  syphilis  have  no 
tendency  to  suppuration. 

Rash  and  sore  throat  coming  on 
some  weeks  later  are  the  only 
real  pathognomonic  features  of 
true  syphilis. 


One  cannot  too  strongly  insist  on  the  fact  that  a  very  large 
majority  of  venereal  sores  have  the  syphiHtic  virus  in  them,  though 
its  presence  is  for  a  long  time  obscured  by  the  more  active  and 
rapidly-developing  septic  microbe,  the  work  of  which  is  soon  pro- 
minent enough.  The  positive  features  of  syphilis  may  later  become 
most  distinct,  but  a  negative  is  proverbially  difficult  to  prove,  and 
nothing  but  six  months  from  the  date  of  inoculation  will  prove  it 
satisfactorily.  The  question  whether  this  is  too  heavy  a  price  to 
pay  for  certainty  belongs  to  the  region  of  treatment,  and  cannot  be 
discussed  here. 


CHAPTER    IV 

DISEASES    OF    THORACIC    ORGANS 

Section  I. — The  Lungs  and  Accessories 

The  principal   symptoms   arising   from  disease  within   the   thorax 
are  : — 

(i)  Pyrexia. 

(2)  Alterations  in  respiratory  movements  and  rhythm. 

(3)  Alterations  in  cardiac  sounds,  position,  and  rhythm  {vide 

Section  II). 

(4)  Pain,  and — 

(5)  Various  other  pressure  effects. 

The  physical  signs  consist  of  alterations  in  the  normal  or 
average  condition  noticed  on — 

(i)  Inspection. 

(2)  Palpation. 

(3)  Percussion. 

(4)  Auscultation. 

I  propose  first  to  analyse  some  of  these  phenomena  from  the 
point  of  view  of  diagnosis,  and  then  to  offer  a  few  remarks  on  the 
individual  diseases  producing  them. 

PYREXIA 

This,  qua  thoracic  disease,  is  only  likely  to  be  present  as  the 
result  of  inflammation  of  some  thoracic  organ,  or  produced  by 
nervous  reflex  from  irritation  of  the  vagus,  with  or  without  inter- 
ference with  respiration  or  circulation. 

Of  the  latter  form  there  is  but  little  in  an  elementary  book  to 


48  ^        DIFFERENTIAL  DIAGNOSIS  chap. 

say.  It  would  certainly  seem  that  hyperpyrexia  might  sometimes 
arise  from  this  source,  for  it  is  seen  occasionally  in  cases  of  peri- 
carditis and  pleurisy,  and  when  rheumatic  hyperpyrexia  is  accom- 
panied by  visible  organic  disease,  this  is  almost  constantly  a 
pericarditis,  so  that  arguments  are  not  wanting  to  establish  the 
position  of  a  reflex  hyperpyrexia  through  vagus  irritation,  though 
other  factors,  e.g.  the  rheumatic  poison,  may  have  a  good  deal  to  do 
with  the  temperature  variations. 

In  cases  of  organic  disease  of  the  intrathoracic  organs,  on  the 
other  hand,  the  thermometer  affords  many  useful  points  in  differ- 
ential diagnosis.  In  cases,  for  instance,  where  the  physical  signs 
tell  us  that  bronchitis  is  present,  it  is  a  common  rule  of  practice  to 
consider  that  a  temperature  of  ioi°  or  over  indicates  the  extension 
of  the  inflammatory  process  to  some  of  the  alveoli,  so  that  broncho- 
pneumonia is  present,  even  though  there  be  no  tubular  breathing, 
etc.,  suggestive  of  consolidation  of  lung,  within  the  range  of  the  ear. 
Again,  we  may  suspect  that  an  undoubtedly  catarrhal  area  has  been 
invaded  by  tubercle,  or  we  may  think  of  tubercle  when  a  persistent 
cough  exists  without  physical  signs  of  a  catarrh ;  here  a  nocturnal 
elevation  of  temperature  with  a  normal  reading  in  the  day  is  a  very 
strong  piece  of  evidence  in  favour  of  the  more  serious  condition, 
though  it  must  be  admitted  that  tubercle  is  sometimes  apyrexial, 
and  simple  catarrh  may  be  febrile  even  after  its  acute  stage  has 
passed.  Lastly,  in  pleurisy  with  effusion,  a  nocturnal  elevation  of 
temperature,  especially  if  associated  with  sweating,  strongly  suggests 
that  the  effusion  is  purulent,  or,  if  proved  clear,  that  it  is  due  to 
concealed  tubercle.  The  non-subsidence  of  a  pyrexia  after  apparent 
removal  of  the  cause,  e.g.  tapping,  must  be  carefully  watched  to 
ascertain  the  meaning  of  the  hitch  in  the  proceedings  ;  and  similarly 
when  a  pyrexia,  whose  cause  is  known  and  whose  course  is  usually 
constant,  as  in  the  common  zymotics,  does  not  follow  the  average 
rule,  pulmonary  complications  must  be  suspected  and  carefully 
looked  for. 

It  is  important  to  remember  that  when  breathing  power  is  very 
seriously  interfered  with,  as  in  some  cases  of  pneumonia  or  broncho- 
pneumonia, or  in  an  ordinary  case  of  bronchitis  becoming  capillary, 
the  temperature  may  sink  and  become  normal,  or  more  probably 
subnormal,  while  the  disease  is  making  rapid  strides  to  a  fatal  issue, 
so  that  a  subnormal  temperature  in  such  cases  is  even  more  to  be 
feared  than  pyrexia  of  moderate,  or  even  severe  degree,  say  up  to 
103.5  or  104.  The  same  may  be  said  in  severe  cardiac  failure 
from  any  cause,  though  increased  temperature  is  here  less  likely  as 


IV  DISEASES  OF  THORACIC  ORGANS  49 

an   initial   phenomenon    except  in  recent   endocarditis,    of  which, 
indeed,  pyrexia  and  a  bruit  are  the  chief  indications. 

In  all  cases  of  old  or  chronic  lung  and  heart  mischief,  the 
thermometer  is  an  important  aid  in  determining  whether  the 
physical  signs  are  produced  by  old  changes  in  the  tissues  or  by 
active  processes  still  going  on.  If  the  former,  there  will  most  prob- 
ably be  no  fever ;  if  the  latter,  pyrexia  may  be  present ;  at  least  if 
pyrexia  is  present,  then  the  changes  are  probably  active. 


Alterations  in  Respiratory  Rhythm 
(a)  Cough 

Cough,  as  we  know,  is  a  peculiar  modification  of  respiration 
which  can  be  produced  voluntarily,  and  can  also  often  be  suppressed 
by  an  effort  of  the  will  when  the  act  would  be  attended  by  pain  ; 
but  it  is  essentially  a  reflex  act  arising  from  irritation  of  nerve 
terminals  or  trunks,  in  direct  or  indirect  communication  with  the 
respiratory  centre,  principally  of  the  vagus  or  of  the  fifth  nerve. 
It  is  designed  primarily  with  the  object  of  removing  this  irritant 
from  the  terminals  of  the  pneumogastric  in  the  air  passages  of  the 
lung;  but  inasmuch  as  the  respiratory  centre  is  incapable  of  dis- 
tinguishing between  an  irritant  of  terminals  and  one  of  nerve  trunks, 
and  between  a  removable  and  an  irremovable  irritant,  the  act  is  in 
many  cases  necessarily  ineffectual.  We  are  thus  led  naturally  to  a 
division  of  coughs  into  (a)  coughs  useful,  (b)  coughs  useless,  the 
former  requiring  to  be  helped,  the  latter  to  be  suppressed  as  far  as 
possible ;  and  hence  our  first  point  in  diagnosis  is  to  try  to  separate 
the  two  classes. 

First,  as  regards  the  sound  and  features  of  the  cough  itself : — 

Cough  Useful  Cough  Useless 

Moist,  accompanied  by  a  rattling  Dry,  barking,  or  ringing  cough, 
or  wheezing  sound  with  each  characteristically  paroxysmal  in 
blast  ;  if  at  first  dry  and  in-  many  cases,  e.g.  whooping  cough 
effectual,  ultimately  results  in  in  later  stages  ;  always  ineffec- 
the  expulsion  of  some  mucus  tual  in  removing  the  essential 
or  other  material  from  the  air  cause  of  irritation.  It  may  re- 
passages  more  or  less  proper-  suit  in  the  bringing  up  of  a 
tionate  to  the  efforts  made.  small  plug  of  mucus,  but  totally 

out  of  proportion  to  the  efforts 


made. 


E 


so 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


JV.B. — In  both  classes  may  be  included  a  few  unusual  or  rare 
cases  of  gross  foreign  bodies  in  the  tubes,  or  of  the  membranous 
casts  of  plastic  bronchitis,  in  each  of  which  the  cough  may  be  dry, 
barky,  and  severe,  or  moist  and  wheezy,  but  may  still  result  in  the 
expulsion  of  the  irritant. 

Now  as  regards  the  clinical  causation  of  the  two  groups.  These 
we  may  tabulate  as  follows  : — 


Cause. 
Disease   of  external 
ear. 


Elongated  uvula. 


Acute  pharyngo-ton- 
sillitis. 


Laryngitis,  bron- 
chitis, broncho- 
pneumonia, ordi- 
nary pneumonia, 
pleurisy. 


Tuberculosis      of 
larynx  or  of  lung. 


Cough  Useless 

Principal  Diagnostic  Points. 

The  evidence  will  be  chiefly  negative,  absence  of 
other  possible  cause  for  a  slight  dry  cough. 
Under  such  circumstances  it  has  only  to  be 
remembered  that  a  foreign  body  in  the  ear,  or 
a  little  eczema,  may  cause  such  a  cough  for 
the  diagnosis  to  be  suggested,  and  the  sugges- 
tion will  lead  to  a  careful  examination  of  the 
part. 

Suspected  by  the  cough  and  tickling  in  the  throat 
being  much  worse  (possibly  only  then  notice- 
able) on  lying  down.  Absence  of  thoracic 
signs  of  disease  and  presence  of  the  long 
uvula  complete  the  diagnosis. 

Cough  (as  opposed  to  mere  laboured  hawking  of 
phlegm)  slight,  but  attended  with  much  pain, 
therefore  often  suppressed.  Condition  obvious 
on  examination  of  mouth  and  pharynx. 

In  all  these  acute  inflammatory  conditions  of  the 
air  passages  the  cough  is,  at  least  in  the  earlier 
stages, — say  twenty-four  to  thirty-six  hours — of 
the  useless  type,  and  may  safely  be  mitigated 
with  sedatives  ;  the  temperature,  the  history, 
and  the  painful  cough  are  sufficient  for  a  tem- 
porary diagnosis.  For  a  complete  one,  vide 
under  the  appropriate  subsections  (pp.  ()j  et  seq.). 

Both  these  forms  of  tubercle,  in  the  stages  of 
deposit,  before  ulceration  or  suppuration  has 
occurred,  are  associated  with  a  troublesome 
dry  cough.  In  the  former  additional  suspicion 
is  aroused  by  hoarseness  or  loss  of  voice,  and 
the  laryngoscope  will  clear  up  the  diagnosis. 
For  a  complete  diagnosis  of  phthisis,  vide 
pp.  84  ^/  seq. 


IV 


DISEASES  OF  THORACIC  ORGANS 


51 


Cause. 
Malignant  or  syphi- 
litic    deposit      in 
larynx   before    ul- 
ceration. 


Tumour  pressing  on 
pneumogastric  or 
its  branches,  or 
on  trachea  or 
bronchi  ;  aneur- 
ysm, enlarged 
glands,  malignant 
growth. 

Morbus  cordis  in 
early  stages. 


Principal  Diagnostic  Points. 

Cough  and  symptoms  similar  to  tubercle,  diagnosis 
made  with  laryngoscope.  N.B. — In  the  later 
ulcerative  stages  of  all  these  deposits  in  the 
lar)-nx,  though  the  cough  may  be  in  some 
degree  useful,  it  is  always  persistent  and  dis- 
tressing to  a  degree  that  renders  some  mitiga- 
tion of  it  necessary. 

Any  of  these  tumours,  in  any  form,  may  cause  a 
dn,',  hacking,  or  brassy  cough,  which  in  itself 
should  arouse  suspicion  of  some  such  condition. 
Absence  of  other  obvious  cause,  and  especially 
if  combined  with  paralysis  of  one  or  both  cords, 
will  be  the  chief  diagnostic  feature,  but  vide 
p.   105  for  further  indications. 

The  back  pressure  of  a  leaking  mitral  will,  on 
any  extra  exertion,  cause  a  cough  which — at 
first,  at  any  rate — is  distressing  and  useless. 
The  diagnosis  depends  primarily  on  the  presence 
of  a  bruit.      Should  this  be  absent  and  yet  no 

-  other  cause  for  a  cough  on  exertion  be  found, 
the  consideration  of  the  heart  sounds  on  p.  125 
will  be  useful. 


Cough  Useful 

As  remarked  above,  cough  may  be  looked  upon  as  useful,  and 
encouraged  accordingly,  when  it  removes  irritating  material  from 
the  air  passages  in  something  like  proportion  to  its  activity  and 
force  (the  force  may  need  reinforcement  in  the  aged  or  debiUtated). 
Hence  we  find  it  in — 

The  later  stages  of  all  acute  inflammatory  affections  of  the  air 
passages  and  lungs  when  secretion  has  become  excessive  or  suppura- 
tion estabhshed,  or  often  enough  when  the  disease  has  become 
chronic. 

The  later  stages  of  phthisis  when  ulceration  and  breaking  down 
of  lung  tissue  has  occurred. 

In  bronchiectasis,  how-ever  arising. 

In  some  cases  of  pleuritic  effusion  or  of  morbus  cordis  when  it 
would  appear  that  the  air  tubes  are  used  as  the  means  of  carrying 
off  excess  of  fluid. 

In  the  bursting  of  abscesses,  empyemata,  etc.,  into  the  tubes. 

The  differential  diagnosis  of  these  conditions  will  be  the  object 


52  DIFFERENTIAL  DIAGNOSIS  chap. 

of  several  sections  in  the  succeeding  pages.  So  far  as  the  mere  act 
of  coughing  is  concerned,  they  offer  no  differentiating  points.  It  is, 
however,  worth  while  to  draw  attention  to  the  suggestions  given  by 
the  time  of  day  at  which  a  cough  is  worse.  If  it  is  worse  at  nighty 
after  the  patient  has  got  warm  in  bed,  the  suggestion  is  that  it  is  due 
to  some  cause  other  than  a  mere  mechanical  stimulus  or  natural 
secretion,  i.e.  in  an  adult  suggestive  of  phthisis  or  pneumonia,  in  a 
child  of  pertussis  or  bronchopneumonia.  On  the  other  hand,  if  the 
cough  is  worse  duriiig  the  active  working  hours  or  on  change  of 
atmosphere^  this  is  suggestive  of  simple  catarrh,  as  in  mild  bronchitis. 
It  is  possible  that  the  explanation  of  this  clinical  fact  may  lie  in  a 
suggestion  that  the  activity  of  the  more  virulent  microbes  is  inde- 
pendent of  the  circumstances  of  the  patient,  whether  active  or 
quiet,  asleep  or  awake,  while  the  milder  ones  may  be  more 
dependent  on  respiratory  activity,  as  we  know  natural  secretions 
are. 

The  Sputum  as  an  Aid  to  Diagnosis 

Sputum  is  the  natural  sequel  to  a  useful  cough.  As  a  guide  to 
the  naming  of  a  disease  it  is  not  often  by  its  naked-eye  characters 
(its  microscopical -bacteriological  examination  is  most  important) 
of  great  capital  value,  but  as  a  guide  to  the  improvement,  or  the 
reverse,  of  the  condition  of  our  patient's  air  tubes,  during  treatment, 
it  is  of  very  great  significance.  It  is  well  to  draw  the  student's  and 
young  practitioner's  attention  to  the  fact  that  the  repeated  physical 
examination  of  the  chest  which  is  allowable,  and  even  necessary,  in 
hospital  work  for  teaching  purposes,  is  not  in  private  practice 
always  advisable ;  and  many  patients  will  so  strongly  object  to  it 
that  some  other  means  must  be  adopted  for  estimating  progress, 
and  none  are  so  useful  as  a  few  questions  on  the  violence  and 
frequency  of  the  cough,  and  the  amount  of  trouble  experienced  in 
getting  up  the  phlegm,  followed  by  an  ocular  and  mental  inspec- 
tion of  the  sputum,  which  should  always  be  kept  for  the  purpose. 

Phlegm,  as  the  natural  secretion  or  excretion  of  the  mucous 
membrane  of  the  air  tubes,  should  be  small  in  quantity,  and  consist 
merely  of  almost  colourless  mucus,  with  occasional  cells  and  detritus 
of  inhaled  particles.  It  is  what  it  should  be,  in  country  dwellers  and 
non-smokers;  but  in  towns,  in  smokers  and  others  with  dusty  occupa- 
tion, it  becomes  more  or  less  coloured  in  agreement  with  these 
factors ;  hence  black  phlegm,  unless  we  see  it  is  due  to  dark  blood, 
need  not  be  a  cause  for  alarm  under  such  circumstances. 


IV  DISEASES  OF  THORACIC  ORGANS  53 

In  disease  the  quantity  is,  as  a  rule,  enormously  increased,  and 
much  besides  mucus  is  present. 

Quantity. — Speaking  of  quantity  only,  quite  apart  from  quality, 
it  is  important  to  note  one  point  particularly,  i.e.  whether  the 
excess  is  brought  up  in  large  mouthfuls  or  gulps  at  a  time,  with 
quiescence  in  the  somewhat  long  intervals,  or  whether  it  arises  from 
an  increased  frequency  in  the  act  of  coughing,  with  but  a  moderate 
expectoration  each  time.  The  former  indicates  or  suggests  to  us 
that  there  is  a  cavity  or  potential  cavity  of  some  kind  communicating 
"with  a  bronchus,  and  emptying  itself  by  cough  at  intervals ;  such 
may  be  bronchiectasis,  or  abscess  either  of  lung  itself  or  neighbouring 
organ,  or  empyema.  The  latter  tends  to  negative  such  a  suspicion 
if  roused  by  other  methods  of  examination,  and  suggests  instead 
a  bronchitis,  bronchopneumonia,  or  ordinary  pneumonia,  with 
excessive  secretion,  but  without  organic  dilation  of  tubes ;  the 
absorption  of  a  pleuritic  effusion,  or  the  presence  of  morbus  cordis, 
will  occasionally  very  much  increase  the  quantity  of  sputum. 

Quality. — As  regards  the  quality  of  the  sputum,  the  following 
are  the  principal  pathological  constituents  to  be  found  by  clinical 
examination  : — 

Mucus  (excess  only  is  pathological), 

Pus,  and  nummulation, 

Blood, 

Bile, 

Lung  tissue. 

Hydatid  booklets  and  other  parasitic  detritus, 

Microbes  (particularly  of  tubercle  and  actinomycosis), 

Foetor, 
on  each  of  which  I  propose  to  make  brief  comments. 

Mucus. — As  this  is  the  natural  secretion  of  the  air  tubes,  it  follows 
that  its  excess  or  defect  is  the  pathological  phenomenon.  In  the 
early  hours  of  a  catarrh  it  is  defective  (hence  cough  useless  and 
sedatives  required).  Later  it  becomes  excessive  but  very  sticky.  This 
excessive  stickiness  is  almost  pathognomonic  of  pneumonia  (cough 
still  useless,  or  at  least  violent  and  out  of  proportion  to  result,  and 
to  be  helped  by  liquefaction  of  phlegm).  This  indicates  an  acute 
bronchitis  or  pneumonia.  Later  still  it  becomes  mixed  with  pus,  and 
looser,  indicating  that  the  catarrh  has  caused  suppurative  processes 
which,  unless  very  excessive,  are  known  not  to  be  of  unfavourable 
omen. 

Fus, — ^As  mentioned  above,  this  is  found  in  the  later  stages  of 


54  DIFFERENTIAL  DIAGNOSIS  chap. 

all  catarrhal  affections  of  the  bronchi,  and  hence,  as  a  rule,  is  of 
little  diagnostic  significance;  it  causes  mucus  to  assume  a 
yellowish  or  green  colouration.  There  are  two  conditions  of 
suppurative  sputum  which  it  is  important  to  bear  in  mind :  {a) 
when  the  pus  comes  up  very  freely  and  almost  pure,  i.e.  without 
much  mucus,  rousing  suspicion  of,  or  corroborating  other  indications 
of,  the  bursting  of  an  abscess  or  empyema  into  an  air  tube,  or  the 
presence  of  bronchiectasis ;  {b)  the  condition  known  as  nummula- 
tion  of  the  sputum,  in  which  small  masses  of  pus  float  quite 
separately  and  isolated  in  the  spittoon ;  it  suggests  the  presence  of 
small  loculi  where  the  pus  can  collect  before  being  expectorated ;  it 
is  seen  in  its  most  typical  form  in,  and  is  very  suggestive  of,  the 
later  stages  of  tubercular  destruction  ;  it  is  found,  but  less  frequently 
and  typically,  in  pneumonia  and  bronchitis,  especially  if  some  of  the 
smaller  tubes  have  dilated. 

Blood. — "  Blood-spitting "  is  a  very  common  complaint,  and 
requires  considerable  care  to  ascertain  its  exact  source,  vide  pp.  150 
et  seq.  Suppose,  however,  we  are  satisfied  that  it  arises  from  some 
pulmonary  affection,  we  have  still  to  consider  its  significance.  It 
may  appear  in  small  isolated  streaks  in  the  mucus,  or  clotted  and 
free,  or  it  may  be  more  intimately  mixed  with  the  sputum,  imparting 
a  uniform  tinge  to  the  excretion. 

If      of        laryngeal     Probably    only    in     streaks     or   tiny  clots,    with 

origin.  pain    in   larynx     and    alteration    of    tone    of 

voice.     Unless  other  source  obvious,  a  laryngeal 

examination    must   be    made,    and    this    will 

clear  up  the  question. 

If  tracheal  or  acute  Again  probably  only  in  streaks  and  tiny  clots  ; 
bronchitis.  other  signs  of  tracheitis  and  bronchitis. 

In  chronic  bron-  Often  profuse,  condition  is  fairly  obvious  in 
chitis.  diagnosis,    but   the  occurrence  of  haemoptysis 

in  the  disease  is  frequently  forgotten. 

In  phthisis.  Whether  in  an    early  or  late  stage  the  haemor- 

rhage may  be  smart,  diagnosis  must  rest  on 
other  factors.  Apices  are  especially  likely  to 
give  added  physical  signs  on  deep  inspira- 
tion.     Bacillus,  if  found,  is  conclusive. 

In  pneumonia.  It  is   especially    in   pneumonia   that    the    blood 

stains  the  sputum  uniformly.  Colour  anything 
from  mere  rusty  to  dark  prune  -  juice ;  the 
darker  the  worse  the  prognosis. 

In  morbus  cordis.  Presence  of  bruits,  or,  more  significantly,    other 

signs  of  cardiac  failure,  vide  p.  124. 


IV  DISEASES  OF  THORACIC  ORGANS  55 

In  malignant  The    sputum     of    patients      with      recognisable 

disease.  malignant  disease  often  contains  small  masses 

of  blood  -  stained  material  likened  to  red- 
currant  jelly ;  the  point  may  be  of  importance 
in  separating  such  from  other  consolidating 
lung  trouble  (vide  p.  105). 

Such  are  some  of  the  main  lines  of  thought  towards  a  diagnosis 
in  cases  of  pulmonary  haemorrhage,  but  it  is  easy  to  see  that  the 
bleeding  itself  or  its  character  is  of  relatively  small  importance ; 
other  factors  of  much  greater  weight  are  involved. 

Bile. — This  is  but  a  very  rare  constituent  of  sputum,  but  if 
present  is  practically  pathognomonic  of  communication  between  an 
air  tube  and  a  pathological  excavation  of  the  liver. 

Limg  Tissue. — If  fragments  of  elastic  tissue  are  found  in  the 
expectoration  (boiling  with  caustic  potash  and  examining  the 
detritus  under  the  microscope  is  the  simplest  plan),  the  important 
caution  is  to  be  sure  that  what  we  see  has  actually  come  from  the 
lung.  It  is  not  enough  to  find  elastic  fibres,  which  may  have  come 
from  tiny  fragments  of  food  accidentally  present ;  they  must  have 
the  shape  of  a  more  or  less  open  figure  8  indicating  their  origin 
from  the  bronchioles  or  alveoli.  If  such  are  present,  they  prove 
pulmonary  ulceration  to  a  demonstration,  and  render  tuberculosis 
almost  certain ;  doubt  can  only  arise  in  some  few  cases  of  chronic 
disease  of  the  lung,  either  fibroid  pneumonia,  or  bronchitis  with 
associated  bronchiectasis.  An  acute  gangrene  will  reveal  itself  by 
other  more  important  features. 

Hydatid  Hooklets,  or  other  parasitic  detritus  or  eggs,  are  of  course 
immediately  pathognomonic  of  their  source. 

Microbes. — The  bacilH  of  tubercle  and  other  bacilli  are  of  course 
equally  pathognomonic ;  the  only  cautions  are,  first,  to  be  sure  that 
the  staining  processes  have  been  properly  carried  out ;  and  secondly, 
to  remember  the  difficulty  of  proving  a  negative,  and  so  excluding 
tuberculosis  too  summarily  from  the  absence  of  bacilli  in  a  few 
fields  of  the  microscope. 

Foetor. — This  proves  that  the  microbes  of  putrefaction  have  not 
only  reached  the  dead  material  of  the  sputum,  but  have  had  time 
to  effect  their  pecuHar  changes  in  it ;  hence  foetor  almost  certainly 
indicates  that  the  sputum  has  lain  for  some  time  in  a  potential  cavity, 
i.e.  a  place  where  such  changes  could  go  on  undisturbed,  or  that  a 
piece  of  lung  has  itself  died  outright,  or  some  foreign  body  is 
present  in  an  air  tube  capable  of  putrefying ;  consequently  careful 
search  must  be  made  for : — 


56  DIFFERENTIAL  DIAGNOSIS  chap. 

(i)  Bronchiectasis.  Usuallyassociatedwithchronicbronchitis.  Phthisi- 
cal cavities  are  curiously  almost  exempt  from 
this  putrefactive  process,  though  their  contents 
have  a  peculiar  mawkish  smell  very  charac- 
teristic. 

(2)  Abscess  of  lung.     The  main  diagnostic  features  of  intrinsic  abscess 

Intrinsic         or  are  {a)  fcetid  expectoration,  which  {b)  consists 

bursting  into  of  nearly  pure  pus,  with  putrefying  detritus, 
lung  from  with-  and  {c)  the  discovery  over  a  localised  area  of 
in.  the  lung  of  pathological  physical  signs  {vide  pp. 

64  etseq.).  Abscess  arising  elsewhere  and  burst- 
ing into  the  lung  will  have  revealed  itself  be- 
fore rupture  probably.  The  foetor  (if  present) 
and  coughing  up  of  quantities  of  pus  merely 
indicate  that  communication  has  been  estab- 
lished with  the  air  tubes. 

(3)  Gangrene.  The  foetor  of  pulmonary  gangrene  is  utterly  in- 

describable ;  once  smelt  it  cannot  be  forgotten, 
and  when  occurring  with  symptoms  of  serious 
blood-poisoning  leaves  no  room  for  doubt  or 
error. 

It  is  well  to  insert  here  a  caution  against  mistaking  foul  breath 
for  foetor  of  sputum ;  the  latter  is  only  one  cause  of  the  former, 
and  that  a  rare  one,  the  nose,  mouth,  and  stomach  being  far  and 
away  the  most  frequent  sources  of  foul  breath. 

To  sum  up  the  diagnostic  value  of  an  examination  of  the 
sputum,  we  may  say  that  nearly  every  disease  of  the  respiratory 
apparatus  has,  or  may  have,  a  form  of  expectoration  which  is  fairly 
characteristic  which,  at  any  rate,  lends  strong  corroboration  to 
other  physical  signs  and  symptoms,  and  at  times  takes  a  leading 
position  as  an  indicator  of  the  essential  condition  of  the  organ — 
improvement  or  the  reverse — under  treatment. 

Besides  cough  and  its  attendant  expectoration,  there  are  one  or 
two  general  alterations  in  respiratory  movements  which  deserve  a 
brief  mention  and  analysis  for  diagnosis. 

Generally  accelerated  Respiration. — This,  apart  from  intentional  or 
voluntary  quickening  of  the  movement,  essentially  means  that  the 
supply  of  oxygen  to  the  tissues  is  insufficient  for  their  immediate 
(it  may  be)  temporary  needs.     This  may  be  analysed  into : — 

A.  Conditions  in  which  an  extra  supply  is  required. 

{a)  Exertion,  A  purely    healthy    and    physiological    condition, 

exaggerated  in  convalescence  when  the  tissues 


IV  DISEASES  OF  THORACIC  ORGANS  57 

are  rebuilding  their  stable  capital  of  nutritional 
material. 
{b)    Pyrexia    arising     Oxidation  is  quickened  throughout  the  body.      I 
from    any    dis-  have  already  (p.   35)   noticed  the  importance 

ease.  of   the    temperature-respiration-ratio   in    draw- 

ing attention  to  pulmonary  complications  when 
other  complaints  of  lung  trouble  by  the  patient 
are  absent.  This  rule  is  particularly  valuable 
in  the  specific  fevers,  when  cough  may  be  de- 
liberately suppressed  because  of  the  pain  it 
causes,  or  when  the  patient  is  too  weak  to 
cough. 

B.  Conditions  in  which  increased  frequency  of  respiratory  movement 
is  required  to  keep  up  the  ordinary  normal  supply. 

(<a:)  Diminished aerat-     Seen  in  bronchitis,  pneumonia,  emphysema,  col- 
ing    surface    in  lapse  of  lung,  phthisis,  etc. ;  in  fact,  any  disease 

lungs.  filling  the  air  tubes  or  destroying  alveoli. 

{b)    Diminished     or     Seen  in  valvular  or  muscular  disease  of  the  heart, 
obstructed    cir-  in  emphysema,  etc. 

culation  of 
blood  through 
the  lungs, 

N'.B. — It  is  probable  that  these  two  causes  never  act  absolutely 
independently.  Pulmonary  disease  in  itself,  e.g.  emphysema,  invariably 
tends  to  obstruct  the  circulation,  and  cardiac  disease  tends  to  fill  the 
air  tubes. 

{c)  Poverty  of  blood      Seen  in  anaemia,  from  whatever  cause  arising, 
in   oxygen   car- 
riers. 

From  the  variety  and  number  of  the  diseases  and  conditions  in 
which  increased  frequency  of  respiration  occurs,  it  will  be  seen  that 
the  act  is  in  itself  not  of  very  great  value  in  differential  diagnosis, 
but  there  are  one  or  two  points  in  it  w^ell  worth  attention  : — 

In  chronic  disease  of  the  lung,  e.g.  phthisis  or  bronchitis,  the 
patient  and  his  tissues,  especially  if  much  wasted,  may  have  got  so 
accustomed  to  the  smaller  supply  of  oxygen  that  shortness  of  breath 
ivill  7iot  be  complai7ud  of,  and  may  even  be  denied.,  until  some  extra 
exertion  is  called  for  ;  w^hereas  in  acute  disease  of  the  lung  the 
shortness  of  breath  is  at  once  obvious,  and  often  very  distressing. 

In  old  people,  whose  chemical  changes  are  not  extremely  active, 
very  serious  lung  and  pleural  trouble  may  come  on  extremely  in- 
sidiously without  any  rise  of  temperature  or  general  discomfort  on 


58  DIFFERENTIAL  DIAGNOSIS  chap. 

the  part  of  the  patient,  except  for  a  httle  shortness  of  breath  ;  hence 
it  is,  in  such  patients,  very  important  to  inquire  specifically  for  such 
complaint,  and  make  a  careful  physical  examination  of  the  chest  on 
the  slightest  suspicion. 

In  young  babies,  again,  and  infants  of  feeble  vitality,  slightly 
quickened  respiration  (it  must  not  be  forgotten  that  their  normal 
respiration  rate  is  from  25  to  35),  accompanied  by  a  little  wheezing, 
may  be  all  the  evidence  of  a  bronchitis  that  is  rapidly  proceeding 
to  become  a  dangerous  and  even  fatal  illness. 

Cheyne-Stokes  breathing  is  a  curious  variety  of  respiratory 
movement,  in  which  the  patient  passes  gradually  from  a  condition 
of  apnoea  (which  may  have  lasted  some  seconds)  through  a  period 
of  steadily  increasing  frequency  up  to  one  of  very  great  frequency 
of  respiration.  It  is  seen  now  and  again  in  almost  every  form  of 
disease  —  uraemia,  chronic  nervous  disease,  concussion  of  brain, 
etc.;  its  morbid  physiology  is  unknown,  and  it  has  no  clinical 
diagnostic  value ;  but  it  is  of  very  grave  prognostic  significance, 
few  recovering  when  the  condition  is  well  marked  as  an  added 
phenomenon  to  the  symptoms  already  present  indicative  of  acute 
disease. 

Dyspnoea  is  a  term  worth  defining,  for  I  find  that  students  so 
frequently  use  it  as  the  scientific  equivalent  of  shortness  of  breath. 
It  really  means  difficulty  of  breathing ;  no  patient  ever  yet  com- 
plained of  "dyspnoea,"  but  many  complain,  and  that  not  indiffer- 
ently, of  "shortness  of  breath,"  or  of  "difficulty  in  breathing," 
terms  which  are  sufficiently  explicit  in  themselves,  and  should  not 
be  confounded.  My  own  teaching  and  practice  is  to  reserve  the 
term  dyspnoea  either  for  those  cases  in  which  the  patient  complains 
of  difficulty  in  breathing,  as,  for  example,  in  most  cases  of  asthma, 
or  in  which  we  have  strong  objective  evidence  of  a  mechanical 
interference  with  the  free  entrance  of  air  to  the  lungs,  e.g.  diphther- 
itic membrane,  spasm  or  paralysis  of  larynx,  pressure  on  the  trachea, 
etc.  Thus  used,  the  term  is  of  some  diagnostic  use,  indicating  one 
of  the  above  conditions  as  opposed  to  the  numberless  causes  of 
"  shortness  of  breath." 

Diaphragmatic  Breathing.  —  This  is  more  or  less  a  natural 
phenomenon,  in  the  male  sex  at  any  rate,  but  may  become  grossly 
exaggerated,  and  assumes  then  very  grave  prognostic  significance. 
My  own  experience  of  it  would  compel  me  to  say  that  it  has  two 
diagnostic  suggestions:  (i)  that  the  nervous  mechanism  of  respira- 
tion is  gravely  interfered  with  either  by  gross  disease  in  the  thorax, 
or  more  probably  by  a  serious  lesion  of  the  nervous  system ;    (2) 


IV  DISEASES  OF  THORACIC  ORGANS  59 

(a  negative  inference)  that  there  is  no  accumulation  of  fluid  in  the 
pleural  cavity. 

Pressure  Effects 

The  thorax  is  certainly  not  an  incompressible  cavity  like  the 
cranium ;  its  roof,  consisting  of  the  dome  of  the  pleura  and  the 
cervical  connective  tissue  and  other  soft  structures,  and  its  floor, 
viz.  the  diaphragm,  are  certainly  both  easily  capable  of  displace- 
ment or  extension  ;  but  the  side  walls,  consisting  of  sternum,  ribs, 
and  vertebrae,  are  comparatively  inextensible,  and  the  individual 
organs  themselves,  except  the  bulk  of  the  heart,  are  so  firmly 
fixed  in  their  places  by  the  mediastinal  tissue,  that  no  very  great 
addition  can  be  made  to  the  bulk  of  an  intrathoracic  organ,  and 
no  neoplasm  can  attain  any  great  size  without  leading  to  compres- 
sion of  some  important  structure,  or  to  manifest  displacement  of 
the  heart.  The  gross  efl'ects  of  the  pressure  or  displacement  are 
readily  enough  recognised  in  most  cases,  but  to  estimate  exactly 
the  diagnostic  value  of  these  various  pressure  effects  requires  a 
considerable  knowledge  of  morbid-anatomical  possibilities  and  of 
the  relative  positions  of  the  several  structures  in  the  thorax.  Into 
these  points  I  do  not  propose  to  enter  fully,  but  I  wish  to  give  an 
analysis  of  the  principles  for  completing  a  diagnosis,  leaving  the 
application  of  these  principles  to  be  worked  out  in  individual  cases. 

We  require  first,  then,  a  list  of  classes  of  structures  that  may  be 
compressed  or  eroded  and  destroyed.     These  comprise : — 

I.    Hollow  vessels  : —  Principal  Results. 

(a)  Lymphatics   and      (Edema  of  chest  wall  or  arm.       If  the  thoracic 
thoracic  ducts.  duct  is  blocked,  chylous  ascites  is  very  possibly 

present. 
(d)  Veins.  (Edema,  as  in  lymphatic  block,  but  the  superficial 

veins    of   the    district    involved    are    probably 

also  enlarged. 

(c)  Arteries.  Alteration  in  the  time  and  volume  of  the    corre- 

sponding pulse  felt  in  an  accessible  situation. 

(d)  Air     tubes     and     Cough    with     little     expectoration,    shortness    of 
lungs.  breath,  inspiratory  dyspnoea  if  large  tube  com- 
pressed, possibly  collapse  of  lung. 

(e)  Heart.  Displacement    of    apex    beat,    possibly    unusual 

bruits  and  altered  rhythm. 
{/)  (Esophagus.  Difficulty  in  swallowing,  or  rather  feeling  of  food 

sticking  and  not  reaching  the  stomach,  possibly 
resfurg-itation. 


6o 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


2.   Nerves  : — 

Of  which  the  most 
important  are  :  — 

{a)  Recurrent  laryn- 
geal. 

(<^)  Phrenic. 

{c)  Pneumogastric 
and  cardiac  plex- 
uses. 

{d)  Lowest  cord  of 
brachial  plexus. 


Principal  Results. 


Spasm  or  paralysis  of  vocal  cord,  hoarseness  or 
alteration  of  voice,  possibly  dyspnoea  and  in- 
effectual cough. 

Hiccough  or  paralysis  of  diaphragm. 

Disturbance  of  heart  beat,  slowing,  quickening, 
or  irregularity,  possibly  vomiting. 

Disturbance  of  function  of  ulnar  and  other  nerves 
of  arm. 


The  nature  of  the  nerve  disturbances  will  be  better  understood 
by  reference  to  p.  31 5. 


3.  Bones — vertebrae, 
ribs,  or  sternum. 


4.  Roof. 

5.  Floor. 


Severe  pain  in  back,  worse  at  night  (this  is  a 
very  characteristic  feature  of  bone  pain,  what- 
ever bone  be  affected  and  whatever  the  cause), 
possibly  felt  all  round  the  chest  from  implica- 
tion of  intercostal  nerves. 

Local  pain,  and  possibly  erosion  with  bulging. 

Visible  bulging  above  clavicle,  either  persistent 
or  on  coughing. 

Displacement  with  easy  palpation  of  liver  below 
the  ribs,  loss  of  free  respiratory  movements  of 
diaphragm. 


These  are  the  principal  results  of  pressure, 
may  be  tluis  tabulated  : — 


The  chief  causes 


The    deformity    is    obvious     on     inspection    and 
palpation. 


I.  Serious  deformity 
of  chest  from  old 
spinal  caries, 
severe  rickets, 
osteomalacia,  par- 
alysis, etc. 

JV.B. — In  a  chest  seriously  deformed  by  old  or  recent  disease, 
it  must  be  borne  in  mind  that  even  a  slight  attack  of  pulmonary 
disease — pneumonia,  bronchitis,  etc. — is  very  apt  to  prove  serious  or 
even  fatal,  owing  to  the  great  curtailment  of  breathing  room.  This 
is  merely  an  illustration  of  the  great  principle  of  the  loss  of  adapt- 
ability for  emergencies  or  extra  work  entailed  by  old  structural 
damage,  a   principle   easily  remembered   in   the   case   of  kidneys, 


IV 


DISEASES  OF  THORACIC  ORGANS 


6i 


livers,  etc.,  but   apt   to   be  forgotten   for  more  obvious  bodily  de- 
formities. 

2.  Aneurysm.  Especially    apt    to   exert    pressure    on    recurrent 

laryngeal  and  other  nerves,  trachea,  left  in- 
nominate vein,  and  on  bone,  but  vide  p.  107 
for  further  details. 

3.  Solid  growths.  Press     especially   on   veins    (intercostal,    azygos, 

etc.)  ;   vide  p.  107. 

4.  Pleuritic  and  peri-     Cause    displacement    of    heart    and    apex    beat 
cardial  effusion.  particularly,  but  vide  p.  102. 


Pain  in  Chest 

Before  considering  the  differential  value  of  a  pain  in  the  chest 
it  is  well  to  locate  the  unhappy  feeling  rather  exactly,  because 
many  people  seem  to  be  unaware  of  the  thoracic  boundaries,  and 
call  the  abdomen  the  chest,  either  out  of  such  ignorance  or  out  of 
modesty.  Even  when  we  have  located  the  pain  with  accuracy,  it 
is  not  always  easy  to  at  once  fix  the  offending  organ,  for  some 
abdominal  troubles,  notoriously  dyspepsia  {vide  below),  may  cause 
pain  referred  to  the  chest,  and  I  have  known  pleurisy  cause  such 
extreme  abdominal  pain  as  to  lead  to  an  erroneous  diagnosis  of 
peritonitis. 

Chest  pain,  if  due  to  organic  disease  situated  within  the  thorax, 
is  almost  invariably  due  to  one  of  the  following : — 


Traumatism. 
Spinal  caries. 

Aneurysm. 
Pleurisy. 

Pericarditis. 

Heart    disease, 
pecially  aortic. 


es- 


History  obvious. 

Pain    of  girdle    character   and  vertebral  spines 

tender,  possibly  also  deformed  in  position. 
May  simulate  caries  in  pain  ;  vide  p.  107. 
Much  worse   on  deep   inspiration,  especially  on 

coughing ;  rub  conclusive. 
Localised  in  precordial  area ;  heart  beats  unusually 

frequent ;  rub  conclusive,  but  vide  p.  127. 
Bruits     heard ;     pain    usually   anginal,  i.e.  very 

severe    tight    cramping  pain,  sudden  in  onset 

and  probably  caused  by  some  exertion,  though 

this  may  be  only  slight. 


Hence  we  see  that  even  a  superficial  physical  examination  is 
not  likely  to  leave  us  long  in  doubt  about  the  pain  of  acute  peri- 
tonitis, calculus,  or  other  gross  organic  disease  of  abdominal  viscera. 
If  the  physical  signs  in  the  chest  are  not  marked,  those  in  the 


62 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


abdomen  are  only  too  obvious.  But  the  relation  between  cause 
and  effect  is  by  no  means  so  easy  to  trace  in  the  case  of  pain  in 
the  chest  arising  from  functional  dyspepsia,  as  mentioned  above. 
Such  a  common  correlation  is  there  between  heart  and  stomach 
that  it  is  now  a  commonplace  of  medicine  to  say,  "  If  a  patient 
complains  of  his  heart,  the  first  suggestion  is  that  his  stomach  is  out 
of  order ;  if  he  complains  of  his  stomach,  don't  let  him  go  without 
examining  his  heart  carefully."  A  few  leading  questions  on  the 
relationship  of  the  pain  to  food,  to  movement,  to  respiration,  will, 
however,  tend  to  clear  matters  up ;  the  follow^ing  points  may  be 
taken  as  guides  : — - 


Pain  in  Heart  Region 


If  of  Gastric  Origin. 

Appears  after  food,  and  apparently 
as  the  direct  consequence  of  its 
ingestion. 

Accompanied  by  feeling  of  fulness 
in  stomach,  often  relieved  mo- 
mentarily by  belching. 

Not  increased  by  walking,  which 
is  easily  possible. 


Heart   sounds    normal    in   rhythm 
and  character. 


If  really  Cardiac. 

Appears  also  quite  irrespective  of 
whether  food  be  taken  or  not. 

No  such  feeling  of  fulness,  not 
relieved  by  eructation  of  wind. 

Increased  by  active  movement, 
which  may  even  be  impossible 
owing  to  the  severity  of  the 
pain. 

Probably  some  cardiac  bruit  pre- 
sent, or  at  least  alteration  in 
rhythm  and  volume  of  pulse 
from  the  normal. 


Notwithstanding  these  differences,  we  must  not  forget  that  the 
two  troubles  may  coexist ;  that,  in  fact,  the  heart  trouble  may  be 
producing  the  dyspepsia,  and  vice  versa,  the  dyspepsia  may  produce 
an  irritable  heart.  We  must  then  leave  the  history  and  other  indi- 
cations to  decide  which  is  cause  and  which  effect,  a  decision  all 
the  more  important  as  treatment  will  be  founded  on  it.  If  the 
heart  mischief  is  primary,  there  are  almost  certain  to  be  other 
indications  of  it— some  shortness  of  breath,  oedema  of  legs,  etc. ; 
it  is  very  improbable  that  dyspepsia  will  be  the  only  symptom ;  per 
contra,  if  dyspepsia  is  the  primary  trouble,  there  will  almost  certainly 
be  a  history  of  discomfort  after  meals  long  antedating  the  pain  in 
the  heart. 

There  is  still  one  form   of  pain  in  the  chest  which  requires 


IV  DISEASES  OF  THORACIC  ORGANS  63 

attention  from  a  diagnostic  point  of  view.  It  is  very  common  in 
my  experience,  situated  about  the  lower  ribs  on  either  side,  but 
very  much  more  common  on  the  left.  It  derives  its  interest  from 
the  entire  absence  of  any  physical  sign  to  account  for  it ;  no  heart 
disease,  no  friction  sounds,  tongue  clean,  bowels  regular,  and  no 
discomfort  after  meals.  A  stitch  in  the  side  from  excessive 
exertion  or  laughter,  etc.,  is  a  common  phenomenon,  due  probably 
to  cramp  of  one  or  two  intercostal  or  abdominal  muscles  or 
segments ;  intercostal  neuralgia,  too,  of  a  typical  darting  character 
I  have  heard  of  and  read  of,  but  seldom  seen  :  but  the  pain  to 
which  I  refer  does  not  agree  with  either  of  these.  It  is  constantly 
present  more  or  less,  but  is  much  increased  by  coughing  or  violent 
respiratory  movements,  and  remains  fixed  in  its  original  situation. 
I  do  not  say  that  I  can  point  to  the  cause  of  all  such  pains,  but  I 
would  draw  attention  to  what  I  believe  to  be  the  explanation  of 
many  of  the  cases. 

Nothing  is  commoner  on  post-mortem  examination  than  to  find, 
besides  the  definite  disease  which  has  caused  death,  one  or  more 
of  the  following  distinctly  pathological  conditions,  evidence  of  past 
local  trouble,  viz.  : — 

1.  Adhesions     of     lung     to     dia-     Diaphragmatic  pleurisy, 
phragm. 

2.  Adhesions    of    spleen     to    dia-     Perisplenitis, 
phragm. 

3.  Adhesions   of   spleen   to   intes-     Perisplenitis. 
tine. 

4.  Adhesions   of  intestine  to   gall     Local  peritonitis, 
bladder  and  liver. 

5.  Adhesions     of     liver     to    dia-     Perihepatitis, 
phragm. 

6.  Thickenings  of  splenic  capsule.      Fibrous  and  even  calcareous. 

The  argument  in  regard  to  such  post-mortem  findings  runs 
thus : — 

1.  They  are  definite  and  indisputable  evidence  of  old  local 
trouble. 

2.  They  offer  no  suggestion  that  the  trouble  was  of  a  disabling 
character,  or  so  severe  as  to  necessitate,  or  perhaps  even  suggest, 
confinement  to  bed  ;  and  hence  they  are  easily  forgotten  after«'ards. 

3.  When  recent,  they  were  in  all  probability  associated  with 
pain,  and  even  as  old  pathological  adhesions  they  probably  cause 


64  DIFFERENTIAL  DIAGNOSIS  chap. 

pain  by  restriction  of  the  natural  movement,  which  would  follow 
ordinary  energising  of  abdominal  and  thoracic  muscles,  Le.  at- 
tempted movement. 

4.  The  pain  would  probably  be  fixed  in  position  about  the 
lower  ribs,  quite  likely  be  made  worse  by  extra  movement,  as  of 
cough,  or  even  by  the  digestive  movements  or  physiological  con- 
gestion of  the  stomach  and  intestine — in  fact,  just  such  a  pain  as 
we  are  discussing. 

5.  From  their  position,  and  from  the  little  movement-in-contact 
of  organs  concerned,  they  would  be  unlikely  to  give  rise  to  an 
audible  rub  or  other  objective  physical  sign. 

On  the  other  hand,  I  am  obliged  to  state  that  I  am  unable  to 
say  definitely  that  these  persons  had  suffered  from  our  present  form 
of  pain,  nor  can  I  say  that  they  had  not  a  definite  disabling 
illness  which  might  have  resulted  in  such  adhesions  and  thicken- 
ings. On  the  whole,  I  am  incHned  to  think  that  the  appearances 
are  too  common  in  proportion  to  histories  of  severe  illnesses,  and 
that  they  do  explain  most  satisfactorily  the  pain  under  discussion. 

PHYSICAL  SIGNS  OF  THORACIC  DISEASE 

As  with  the  symptoms,  so  with  the  physical  signs  of  intra- 
thoracic disease.  I  do  not  propose  to  go  systematically  through 
each  and  all,  but  merely  to  touch  on  those  points  which  are  of 
special  diagnostic  value,  or  on  which,  experience  in  teaching  has 
shown  me,  the  ordinary  text-books  hardly  lay  sufficient  stress. 

Comparison  of  the  Two  Sides 

It  cannot  be  too  much  insisted  upon  that  the  thorax  in  each 
and  every  individual  is  a  closed  box — a  drum,  in  fact — with  its 
own  amount  of  external  covering  or  damper  of  vibration,  its  own 
individual  shape  and  build — in  fine,  its  own  complete  group  of 
special  peculiarities ;  con^-equently  it  is  impossible  to  lay  down  any 
law  as  to  what  should  constitute  its  normal  shape,  or  the  normal 
sound  elicited  by  striking  it.  There  is  no  such  thing  as  an  absolute 
guide  to  discriminate  the  normal  from  the  abnormal ;  that  which 
would  be  natural  in  the  chest  of  a  healthy,  stout  woman,  or  in  a 
baby,  or  even  in  an  old  deformed  chest,  would  be  distinctly  patho- 
logical in  the  chest  of  a  thin  man,  an  adult,  or  in  a  well-formed 
chest.     Our  only   reliable  guide,  then,  is  a  comparison  of  the  two 


IV  DISEASES  OF  THORACIC  ORGANS  65 

sides  of  the  same  chesty  combined  with  experience  of  average  chests ; 
and  be  it  remembered  that  the  two  sides  must  be  examined  and 
compared  at  corresponding  points  and  in  a  similar  manner.  It  is 
no  good  comparing  any  of  the  physical  signs,  seen,  felt,  or  heard, 
of  the  front  or  axiliary  region  of  one  side  with  those  of  the  back  or 
suprascapular  region  of  the  other,  nor  is  it  any  good  to  lay  the 
pleximeter  finger  along  the  ribs  and  spaces  in  one  case,  and  across 
them  in  another.  Thus  compared,  a  httle  sweUing  or  oedema  on 
one  side  only,  a  Httle  difference  in  movement,  in  tactile  vocal 
fremitus,  in  dulness  on  percussion,  and  especially  in  loudness  and 
distinctness  of  breath  and  voice  sounds  acquires  an  enormous 
increase  in  importance  from  what  it  would  have  if  the  (possibly) 
pathological  change  were  found  on  both  sides  to  the  same  degree. 
In  one  case  disease  past  or  present  is  there ;  in  the  other  we  are 
probably  dealing  with  a  natural,  if  not  healthy  (as  in  old  deformity), 
condition.  Never  examine  one  side  of  a  chest  only,  however  obtrusive 
be  the  local  co??iplai?it  of  the  patieftt ;  compare,  compare,  compare  I  ! 

Physical  Signs  give  Physical  Conditions  only 


This  limitation  in  the  diagnostic  utility  of  the  physical  examina- 
tion of  the  chest  is  too  apt  to  be  lost  sight  ?)f,  and  deserves 
emphasis.  It  enables  us  to  see  a  bulging  and  motionless  chest, 
but  it  does  not  decide  the  reason  for  this.  It  proves  the  presence 
of  undue  secretion  in  the  air  tubes,  but  it  does  not  give  us  the 
tubercle  bacilli  which  may  be  causing  it.  Dulness  on  percussion 
does  not  decide  between  serum,  blood,  and  pus ;  and  external 
signs  of  internal  pressure  leave  aneurysm  or  malignant  growth  still 
in  doubt.  Bearing  this  limitation  in  mind,  we  may  proceed  to 
consider  what  can  be  learnt  by  it. 

Inspection 

The  principal  points  noticed  on  inspection,  and  their  pre- 
liminary indications,  may  be  thus  sketched  out : — 

Old  or  permanent  Probably  symmetrical,  and  causing  forward  pro- 
deformity.  Passed  jection  of  sternum,  or,  per  contra,  considerable 
rickets.  depression  of  sternum  and  costal  cartilages. 

Old  spinal  curvature.      Probably     asymmetrical,    hump     on     back,     and 

twisting  on  vertebral  axis. 
Emphysema.  Rounded,  barrel-shaped  chest,  with  but  little  re- 

spiratory movement. 
F 


66 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


A^.^. — All  three  will  possibly,  and  even  almost  certainly,  materially 
alter  the  results  of  percussion  and  auscultation,  owing  to  changes  of 
position  in  the  organs  and  alteration  in  lung  structure. 


Recent    bulging 
one  side. 


Fat  or  thin  chest. 


Enlarged  veins. 


CEdema. 


Local  tumour. 


of  Suggests  a  large  accumulation  of  fluid  in  pleura, 
or  a  new  growth.  Measure  the  two  sides  to 
see  if  the  increased  size  of  one  is  real,  or 
apparent  only.  Look  for  oedema  of  one  side 
or  anything  like  a  local  bulging  or  pointing. 

Remember  fat  is  a  bad  conductor  of  any  vibra- 
tions ;  the  condition  is  obvious  enough  in 
itself,  but  must  be  remembered  in  listening  to 
or  percussing  the  chest. 

An  important  sign  of  obstruction  to  the  venous 
return  of  blood.  If  due  to  cardiac  disease  or 
to  generalised  lung  mischief,  it  will  be  noticed 
chiefly  in  the  neck,  jugulars,  etc.  ;  if  due  to  a 
local  pressure  (aneurysm  or  growth),  more 
likely  in  the  walls  of  the  chest,  or  arms,  and, 
possibly,  abdomen. 

If  confined  to  one  arm  or  one  side  of  the 
chest,  it  is  very  strongly  suggestive  of  a 
malignant  growth  with  much  local  pressure. 
If  general,  more  likely  to  be  only  part  of  a 
renal  or  cardiac  dropsy. 

If  only  connected  with  skin  or  muscles,  belongs 
to  the  domain  of  surgery.  If  evidently  coming 
from  within  the  thorax,  may  be  a  malignant 
growth,  an  aneurysm,  or  a  pointing  empyema. 


Palpation 
By  feeling  the  chest  we  shall  perceive  : — 


CEdema. 


Tactile  vocal  fremitus  is  increased 
by  anything  which  allows  of  a 
freer  vibration  of  the  chest  wall 
in  response  to  the  vibrations  of 
the  voice,  hence  noted  in — 


Already  seen  by  inspection,  but  its 
limits  are  best  ascertained  by 
the  present  method  of  examina- 
tion. 

(a)  Thin  chests,  or  in  parts  of  the 
chest  least  covered. 

(d)  More  powerful  voice  of  a  man, 
and  in  deeper  tones. 

(c)  Consolidation  of  the  lung,  of 
whatever  nature,  provided  that  it 
still  remai7is  i7i  iinniediate  con- 
tact with  the  chest  wall. 


IV 


DISEASES  OF  THORACIC  ORGANS 


67 


Is  diminished,  per  contra^  by  any- 
thing that  damps  off  the  vibra- 
tions. 


Position  of  heart's  apex  beat. 


Thrill  of  heart  beat. 


{d)  Occasionally  by  very  large  effu- 
sions into  the  pleura  completely 
compressing  the  whole  lung. 

(«)  Fat  chests  and  parts  well 
covered  either  by  fat  or  muscle, 

{b)  Less  powerful  voice  vibrations 
in  women  and  children,  and 
higher  tones. 

{d)  Separation  of  the  lung  from 
the  chest  wall  by  fluid  collections, 

id)  Growths  of  parietal  pleura  not 
involving  visceral  layer  or  lung. 

Vide  pp.  123  and  133.  Not  felt  in 
fat  people  very  often,  nor  in 
emphysema.  Fluid  effusions  in 
pleura  are  the  great  cause  of 
displacement. 

Vide  p.  114. 


Percussion 

By  percussion  we  estimate  the  relative  degrees  of  resiUency  or 
elasticity  of  the  chest  wall,  and  get  a  note  varying  in  tone  and 
quality  from  hyper-resonance  to  complete  dulness, 

ResiUe7icy  or  elasticity  of  wall  can  only  be  properly  appreciated 
when  the  finger  is  used  as  the  pleximeter  (hence  the  absolute  objec- 
tion to  the  use  of  all  artificial  pleximeters  of  any  material),  and  a 
knowledge  of  its  varying  degrees  in  deformed  chests  and  in  health, 
its  absence  or  presence  with  associated  signs  in  disease,  can  only  be 
gained  by  experience ;  it  cannot  be  communicated  by  writing,  but 
once  acquired  its  value  is  very  great.  We  may  classify  its  essential 
features  as  under,  with  their  indications : — 


Its  complete  pre- 
sence with  ordin- 
ary but  var}'ing 
degrees  of  reson- 
ance. 


Its  presence  with  a 
note  known  as 
dull  gives  an  im- 


Indicates  that  the  parietal  pleura  is  practically 
healthy,  free  from  any  degree  of  deposit  or 
growth,  and  not  thickened  to  any  great  extent, 
though  it  may  be  adherent  to  the  visceral 
layer  ;  and  that  there  is  no  extensive  pleural 
effusion.  Pneumothorax,  emphysema,  or 
bronchitis  and  other  lung  conditions  are  not 
thereby  excluded. 

This  is  found  in  pneumonia  and  other  conditions 
of  consolidation  of  the  lung,  provided  that  it  is 
not  separated  from  the  chest  wall  dyjlidd,  a7id 


68  DIFFERENTIAL  DIAGNOSIS  chap. 

pression  as  though  that  the  parietal  pleura  is  not  imcch  implicated. 

one  were   percus-  This  is  the  special  utility  of  the  phenomenon, 

sing  a  thick  piece  viz.  to  decide  as  to  whether  a  pneumonia  is  or 

of  wood — a  wood-  is  not  accompanied  by  much   pleural  effusion, 

eny  tone.  The  exploring  needle  is  the  only  other  method 
of  determining  the  point. 

Its    absence   with   a  This  indicates  a  pleural  effusion  of  considerable 

note     known     as  extent,  or  a  marked  thickening  of  the  pleura, 

dull  gives  an  im-  but — N.B. — It  does  not  give  the  reason  for  the 

pression  as  though  effusion  or  thickenings  a  new  growth^  recent  in- 

one  were   percus-  flammation^  or  long  antecedent  disease. 
sing  a  brick  wall 
or  the  thigh,  and 
renders    the    dul- 
ness  absolute. 

It  will  be  noticed  that  these  indications  are  directed  almost 
entirely  to  the  condition  of  the  pleura,  or  to  the  introduction  of 
considerable  consoHdation  of  the  lung.  The  reason  for  this  is  in 
general  terms  easy  to  see,  viz.  the  elasticity,  and,  I  may  say,  the  note 
elicited,  depend  entirely  on  the  capability  of  the  part  struck  to 
vibrate.  This  capability  is  fixed  primarily  by  the  shape  (including 
old  deformity  now  become  the  original  shape),  structure,  etc.,  of  the 
chest  {vide  supra\  and  is  diminished  (or  increased)  more  by  an  altera- 
tion in  the  pleura  and  its  contents,  e.g.  fluid  (or  air-increase)  and 
introduction  of  considerable  underlying  solidification,  than  by  any- 
thing else. 

JVote  elicited  apari  from  Resiliency  of  Wall. — To  explain  accurately 
the  variations  in  this  note  is  not  so  easy  as  the  explanation  of  the 
variations  in  general  elasticity  of  the  chest  wall,  but  it  seems  fairly 
obvious  that  if  a  certain  combination  of  healthy  lung,  pleura,  and 
other  structures,  including  the  chest  wall,  gives  in  response  to  a  blow 
a  certain  note,  then  an  alteration  in  any  of  these  organs  or  condi- 
tions should  alter  the  note  at  the  spot  where  the  alteration  exists.  If 
this  be  not  an  entirely  satisfactory  scientific  explanation,  it  is,  at  any 
rate,  the  expression  of  a  clinical  fact  learnt  by  experience ;  and  hence 
the  incalculable  importance  of  comparing  the  two  sides  of  the  chest 
for  detecting  mischief  on  one  side  only.  We  must  not  forget,  how- 
ever, in  this  comparison,  the  asymmetrical  position  of  the  organs  in 
the  chest,  the  heart  on  the  left,  the  liver  below  on  the  right,  and 
the  peculiar  course  of  the  aorta,  with  asymmetry  of  its  main  trunks. 
It  is  not  worth  while  to  attempt  to  tabulate  the  clinical  causes  that 
may  produce  alterations  in  the  percussion  note,  but  attention  may 


IV  DISEASES  OF  THORACIC  ORGANS  69 

be   drawn    to   the   paragraphs   on    the   diagnosis  of  early  phthisis, 
pneumothorax,  excavation  of  lung,  etc. 


Auscultation 

By  the  application  of  the  ear  (immediate)  or  of  some  form  of 
stethoscope  (mediate  auscultation)  to  the  chest,  we  try  to  appreciate, 
and  then  estimate  the  meaning  of,  any  sounds  which  are  produced 
by  the  natural  movements  of  respiration  and  circulation  ;  or  we 
apply  artificial  means  such  as  tapping  or  shaking  for  the  same  pur- 
poses.     These  sounds  may  be  subdi\'ided  in  their  origin  into  : — 

A.  Those  arising  in  and  transmitted  through  the  air  tubes, 
including — 

(i)  The  natural  sounds  of  the  passage  of  the  respired  air. 

(2)  Adventitious,  or  sounds  added  on  to  these  natural  ones, 

but  still  simply  respiratory  in  causation. 

(3)  The  sounds  produced  by  the  voice. 

B.  Those  arising  from  pathological  conditions  of  the  pleura  : — 

Friction  sounds. 
Creaking. 

C.  Sounds  produced  artificially  by  tapping  the  chest,  and  succus- 
sion. 

Z>.  Produced  by  the  circulatory  apparatus.  Vide  subsequent 
section. 

As  regards  their  characters  and  meanings,  we  may  classify  them 
as  follows : — 


A.   ( I )  Natural  Breath  Sounds 

Point  where  heard.                    Normal  sounds.  Significance. 

Over        larynx        and      Inspiration  and  expira-  In   laryngeal    obstruc- 

trachea.                                tion,      distinctly     a  tion      stridor      and 

noisy,    non- musical  hoarseness   may    be 

rush     of    air,     and  detected, 
both     equally    so  = 
tracheal  breathing. 


70 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Point  where  heard. 
Over  larger  bronchi, 
e.g.  interscapular 
space  or  R.  sterno 
clavicular  articula- 
tion. 


Normal  sounds. 
Inspiration  louder 

than  expiration,  but 
the  latter  very  dis- 
tinct and  audible  = 
bronchial  or  tubular 
breathing. 


Over     ordinary     lung 
tissue. 


Inspiration  distinct, 
ending  in  or  con- 
stituting vesicular 
murmur ;  expiration 
scarcely  or  not  at 
all  heard. 


Significance. 

Has  no  abnormality  in 
itself,  only  becomes 
abnormal  by — 

{a)  Being  heard  in  the 
wrong  place  =  too 
free  conduction 

through  solid  lung 
or  dilated  tube. 

{p)  Not  being  heard 
in  the  right  place 
from  compression  of 
a  tube,  etc. 

Its  absence  is  certainly 
abnormal,  e.g.  over 
lung  solidified  by  any 
cause.  In  babies, 
in  unusually  thin 
adults,  and  in  one 
lung  which  is  doing 
the  work  of  two, 
the  vesicular  mur- 
mur is  undoubtedly 
exaggerated,  and 
constitutes  the  harsh 
breathing  of  some 
authors.^ 


(2)  Additional  or  Adventitious  Sounds  are  in  their  nature  essentially 
pathological,  so  we  have  only  to  discuss  their  variations  and  mean- 
ing.    They  may  be  subdivided  as  follows  : — 

I.   Interrupted :  ^ 

I.  Fine  sounds  (crepitations)  are  such  as  would  be  pro- 
duced by  the  separation  of  two  sticky  surfaces,  that 

^  Some  authorities  on  auscultation  will  not  admit  the  use  of  the  term  "  harsh 
breathing,"  but  I  must  say  I  know  of  no  other  term  that  can  better  describe  the  sounds 
heard  in  the  three  conditions  mentioned  above. 

^  By  thus  strictly  defining  the  terms  "crepitations"  and  "rales"  according  to 
the  time  in  the  respiratory  cycle  in  which  they  are  heard,  it  seems  to  me  that  they 
gain  in  accuracy  for  use,  and  indeed  also  in  meaning  and  significance.  The  adjectives 
"  coarse  "  and  "  fine  "  may  still  be  used  for  either,  occurring  in  its  proper  time  ;  and 
from  the  coarseness  or  the  reverse,  and  from  the  time  definition,  we  may  form  a  tolerably 
accurate  opinion  of  either  (i)  the  probable  size  of  the  tube  in  which  the  sound  arises  ; 
(2)  whether  the  air  has  an  actual  thoroughfare  through  the  tube,  or  only  goes  into  and 
back  again  out  of  it  ;  (3)  the  state  of  the  secretion,  the  more  liquid,  the  coarser  the 


IV 


DISEASES  OF  THORACIC  ORGANS 


71 


is,  in  fact,  the  actual  cause  of  them,  and  their  place  of 
origin  is  the  alveoH  and  very  finest  air  tubes  of  the 
lung.  They  are  heard  during  inspiration  only. 
2.  Coarser  sounds  and  moister  (rales)  are  produced  by  the 
passage  of  air  through  a  more  or  less  viscid  secretion, 
and  represent  the  bursting  of  air  bubbles  in  the  fluid  ; 
they  are  produced  in  all  tubes  larger  than  those 
causing  crepitations  only  by  the  passage  of  air 
through  the  secretion.  They  are  heard  therefore  during 
doth  expiration  and  inspiration. 

XL   Continuous  sounds  : 

These  are  the  equivalent  of  the  term  rhonchus  as  used 
by  the  late  Dr.  Fagge,  the  main  point  of  the  defini- 
tion consisting  in  the  sound  remaining  at  a  certain 
level  or  pitch,  possessing,  in  fact,  a  certain  musical 
tone  and  quality  throughout  inspiration  or  expiration, 
or  both.  Of  the  sounds  themselves  there  are  many 
varieties :  whistling,  cooing,  snoring,  etc.,  according 
to  the  depth  of  tone  or  originality  of  term-invention 
of  the  listener.  They  are  produced  by  secretion 
adhering  in  local  masses  to  the  wall  of  a  larger  tube, 
thus  forming  a  sudden  and  adventitious  narrowing  of 
the  lumen  round  which  the  air  passes  with  a  musical 
note. 


(3)    Voice    Sounds, 
Palpation.) 


(For   Tactile  Vocal   Fremitus   vide   under 


Over    trachea 
larynx. 


and 


Over  larger  bronchi. 


Abnormally. 

Hoarseness  the  only 
detectable  variation, 
owing  to  irregular 
growths  or  secretion 
covering  the  cords. 

No  idiopathic  abnor- 
mality, only  abnor- 
mal like  the  breath 
sounds  by  hetero- 
topy. 

sound,  and  the  more  likely,  in  the  finer  tubes,  to  allow  air  to  actually  bubble  through 
it  both  ways.  The  two  may  both  occur  in  the  same  breath  consecutively  to  one 
another,  a  circumstance  which  would  strongly  suggest  that  an  alveolar  or  capillary 
affection  were  supervening  on  a  catarrh  of  the  larger  tubes,  a  most  useful  danger 
signal,  therefore. 


Normally. 
Loud    and    fairly    dis- 
tinct. 


Not  so  loud,  and  more 
indistinct. 


72 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Over  lung  tissue. 


Normally.  Abnormally. 

Mere    confused    mur-     Increase     of     spoken 
mur  or  not  at  all.  words    (broncho- 

phony) denotes  a 
pathological,  in- 
creased facility  for 
transmission  from 
the  larynx  (solidifi- 
cation of  structure, 
dilated  or  ruptured 
tube,  cavity,  etc.). 
Increase  in  whispered 
words  (pectoriloquy) 
denotes  still  greater 
facilities  for  sound 
transmission  from 
the  larynx.  Altered 
sound  of  voice,  only 
one  noticeable  form 
(aegophony),  a  pecu- 
liar bleating  tone 
strongly  character- 
istic, if  not  patho- 
gnomonic, of  pleural 
effusion. 

In  addition  to  the  above  classes  of  regular  voice  and  breath 
sounds,  we  must  notice  one  or  two  important  modifications  of  them. 

Cavernous  Breathing  is  primarily  an  exaggeration  in  loudness  of 
tubular  breathing,  but  it  has  in  addition  a  musical  character  of  its 
own — comparable  to  the  notes  produced  by  blowing  over  the 
mouth  of  an  empty  bottle,  and  due  to  the  same  essential  cause, 
viz.  interfering  currents  of  air  echoing  in  a  hollow.  When  heard 
in  typical  form  this  cavernous  breathing  is  characteristic  of  a  cavity, 
pulmonary  or  pleural,  communicating  freely  with  a  tolerably  large 
bronchial  tube. 

Tinkling  Sou7ids  produced  by  the  falling  of  drops  into  the  body 
of  a  liquid  contained  in  a  resonating  chamber ;  hence  they  are  only 
heard  when  the  liquid  has  been  violently  driven  over  the  surface 
of  either  a  pulmonary  or  pleural  cavity  by  coughing  or  succussion. 

Cogwheel  Respiration  is  a  peculiar  form  of  interrupted  inspiration, 
as  though  the  air  entered  in  a  series  of  little  jerks.  It  is  almost  con- 
fined in  its  appearance  to  the  upper  lobes  of  the  lungs,  and  was 
formerly  thought  to  have  much,  now  only  a  very  little,  significance 


IV  DISEASES  OF  THORACIC  ORGANS  73 

as  indicating  early  stages  of  phthisis,  causing  unequal  difficulty  of 
air  entrance  into  certain  lobules.  My  own  experience  would  lead 
me  to  say  that  it  is  frequently  met  with  in  perfectly  healthy  lungs, 
and  that  its  chief  significance  is  a  very  minor  one,  viz.  that  the 
patient  is  nervous,  and  totally  unaccustomed  to  breathe  by  in- 
tentional or  voluntary  movements. 

B.  Pleural  Friction  Sounds  are  well  known,  to-and-fro  rubbing 
sounds.  There  are  only  two  sources  of  difficulty  in  their  diagnosis : 
the  one  is  to  separate  them  from  fine  crepitations,  and  the  other 
from  pericardial  friction  ;  the  latter  is  identical  in  character.  From 
the  former  they  are  separable  by  being  coarser,  and  sounding  more 
immediately  in  contact  with  the  stethoscope,  but  principally  and 
essentially  by  being  heard  both  with  expiration  and  inspiration  ; 
a  doubtful  sound  heard  wdth  both  movements  must  be  either  a  rub 
or  rales,  and  the  latter  will  be  evidently  bubbling.  The  need  for 
separating  them  from  pericardial  friction  sounds  arises  only  in  the 
neighbourhood  of  the  pericardium,  and  there  the  simple  manoeuvre 
of  listening  while  the  patient  holds  his  breath  will  usually  be  suffi- 
cient, pleural  sounds  then  of  course  ceasing,  except  in  the  occasional 
cases  when  pleuro-pericardial  adhesions  exist,  and  then  the  import- 
ant diagnostic  point  is  to  recognise  by  the  continuance  of  the  sound 
during  the  cardiac  cycle  that  the  pericardium  is  affected. 

Pleural  Creeks  are  rare,  and  only  heard  in  exceptional  cases  of 
very  old-standing  chronic  dry  pleurisy. 

C.  Sounds  heard  by  Tapping  the  Chest  and  by  Succussion. — These 
include : — 

Bell  Soimd^  the  ringing  echo  across  a  chest  produced  by  laying 
one  coin  on  the  w^all  and  striking  this  with  another  coin.  The 
necessary  condition  for  its  production  is  a  fairly  large  empty  space, 
and  hence  it  is  useful  in  detecting  a  pneumothorax,  and  its  presence 
may  be  corroborative  of  other  evidence  of  a  pulmonary  cavity. 

Splashing  Sounds  produced  by  shaking  the  patient ;  can  be  but 
seldom  required,  but  indicate,  when  heard,  air  and  fluid  in  the 
pleura. 

This  classification  gives  in  a  fairly  comprehensive  and  com- 
prehensible manner  the  chief  ordinary  pathological  sounds  heard 
in  the  thorax.  For  these  abnormalities  of  natural  phenomena  my 
chief  aim  has  been  to  indicate  the  principles  and  reasons  which, 
when  well  grasped,  wdll  give  a  rational  foundation  for  explaining  any 
others  that  may  be  found  in  a  given  case.  In  practice  the  difficulty 
is  not  so  much  to  hear  and  understand  the  physical  meaning  of 


74  DIFFERENTIAL  DIAGNOSIS  chap. 

intrathoracic  sounds,  as  to  know  what  name  others  have  given  to 
the  sounds  we  hear,  and  thus  to  avoid  serious  misunderstandings 
and  confusions  of  nomenclature.  Tubular  and  bronchial  breathing, 
harsh  breathing,  rales  and  rhonchi  and  crepitations  are  illustrations 
of  disputed  points  in  affixing  labels  to  aural  perceptions.  I  here 
assume  tubular  as  identical  with  bronchial  breathing,  and  shall 
endeavour  in  the  succeeding  paragraphs  to  follow  my  own  defini- 
tions of  the  remaining  sounds. 

Having  thus  cleared  a  good  deal  of  the  ground  of  symptoms 
and  physical  signs,  we  will  now  proceed  to  discuss  some  of  the 
diseases  on  which  the  phenomena  depend. 


LARYNGEAL  AFFECTIONS 

The  symptoms  that  are  likely  to  call  attention  to  the  larynx  as 
the  seat  of  disease  are  : — 

(i)  Pain  felt  locally. 

(2)  Cough,  at  first  almost  certainly  useless,  and  only  later,   if 

ever,  useful,  i.e.  with  equivalent  expectoration. 

(3)  Especially  a  combination  of  (i)  and  (2). 

(4)  Alterations  in  voice,  hoarseness,  huskiness,  aphonia,  etc. 

N.B. — In  one  great  and  dangerous  group  of  laryngeal  affec- 
tions, viz.  paralysis  of  abductors  from  disease  at  a  distance,  there 
are  very  often  no  symptoms  whatever  (if  a  possible  slight  shortness 
of  breath  be  excepted),  and  the  condition  is  only  discovered  by 
laryngoscopic  examination,  either  as  a  routine  matter  or  because 
other  features  of  the  patient's  complaints  have  suggested  that  a 
paralysis  might  be  found. 

,  The  causes  to  which  those  symptoms  may  be  due  are  inflam- 
mation, acute  and  chronic,  new  growths,  and  paralysis  of  laryngeal 
muscles.  To  endeavour  to  associate  symptoms  with  causes  and  to 
make  an  exact  diagnosis  without  a  laryngoscopic  examination  is 
simply  to  attempt  the  impossible,  and  in  what  follows  the  final 
necessity  of  such  examination  must  always  be  assumed,  though  a 
strong  degree  of  probability  may  certainly  be  arrived  at  by  a  fair 
consideration  of  the  history  and  circumstances  of  the  case. 

Hoarsetiess  of  voice,  if  it  occurs  in  a  child,  is  almost  certainly  due 
to  either  acute  laryngitis  (simple  or  membranous)  or  to  papillo- 
mata  of  the  cords.  Ulcers  of  syphilitic,  tubercular,  or  malignant 
nature  are  practically  unknown  in  childhood,  and  so  is  paralysis 


IV 


DISEASES  OF  THORACIC  ORGANS 


75 


of  the  cords,  except  post  -  diphtheric,  and  then  the  history  is 
tolerably  obvious  on  slight  inquiry.  The  acute  pyrexial  illness  with 
catarrh  and  obvious  faucial  congestion  will  easily  decide  that  acute 
laryngitis  is  present,  but  only  the  laryngoscope  will  prove  that  there 
is  or  is  not  also  a  papillomatous  condition,  or  show  a  case  of  pure 
and  primary  false  membrane  of  the  larynx.  In  adults  the  same 
hoarseness  of  voice  may  have  the  ulcers  above  mentioned  as  addi- 
tional causes,  but  not  every  conjunction  of  apical  phthisis  with 
hoarseness,  of  gumma  of  the  liver,  with  the  same  voice  disturbance, 
has  distinct  ulceration  of  the  cords  as  the  necessary  and  sole  cause 
of  this  latter  symptom.  Phthisical  and  syphilitic  patients  are  not 
exempted  from  a  simple  laryngeal  catarrh. 

The  following  table  gives  the  main  points  of  distinction  between 
the  various  forms  of — 


Ulcers  of  the  Larynx 


Tubercular. 

Slow  in  progress,  and 
not  much  destruc- 
tion till  a  long  in- 
terval has  passed. 

Shallow,  superficial 
ulcers,  without  much 
swelling  or  infiltra- 
tion. 


Curiously  painful  on 
swallowing ;  com- 
moner from  say 
twenty  to  forty-five 
years. 

Almost  certainly  evi- 
dence of  pulmonary 
infection  of  tubercle, 
of  chronic  type. 

Cords  freely  movable. 


Syphilitic. 

Rapid  in  extension 
when  once  broken 
down. 

Deep,  ragged,  sloughy 
ulcers,  with  much 
tumefaction. 


Little  painful ;  com- 
moner from  say 
thirty-five  to  fifty. 


Pulmonary  association 
of  a  chronic  type  ; 
very  rare  ;  may  be 
septic  aspiration- 
pneumonia. 

Cords  not  so  free. 


Malignant. 

Intermediate  in  rapid- 
ity. 


Ulcer  itself  not  very 
deep,  but  much  ex- 
cess of  tissue  for- 
mation, and  not 
much  simple  swell- 
ing. 

Little  painful ;  com- 
moner over  fifty. 


If  lungs  affected  at 
all  it  is  with  acute 
septic  bronchopneu- 
monia. (Schluck- 
ungs-pneumonie, ) 

Cords  often  quite  fixed 
and  immovable. 


76 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Laryngeal  Paralyses 

The  functions  of  the  larynx  with  its  vocal  cords  are  three. 
These,  with  their  natural  nerves  and  muscles,  may  be  thus  tabu- 
lated : — 


Function. 

Action  of  Cords. 

Muscles. 

Nerve. 

Speech 

Approximated 
Made     tense     with 

Arytenoids,          lateral 

crico-arytenoids 
Crico-thyroid 

Recurrent 

laryngeal. 
Superior 

varying      tension 

laryngeal. 

in    voice    expres- 

sion 

Cough  (or  extra- 
ordinary   res- 
piration) 

First  opened  by 

then  firmly  closed  by 
then       suddenly 

Posterior  ^    crico-aryte- 

noid 
All  the  other  muscles 

Recurrent 
laryngeal. 

opened  by 

Force   of    air   and    re- 
laxation of  adductor 
muscles.    Possibly  by 
action     of    posterior 

Ordinary  breath- 

Very   little    move- 

crico-arytenoid 
Slight  abduction  in  in- 

Recurrent 

ing 

ment,    but    what 
there  is  tends  to 

spiration  ?          Slight 
adduction  in  expira- 

laryngeal. 

allow      free 

tion?  (No  movement 

entrance,        with 
gradual  exit  of  air 

according  to  Semon) 

We  should  naturally  expect,  then,  that  paralysis  of  muscles  should 
interfere  with  some  or  all  of  these  functions.  In  the  main  the  in- 
ference is  correct,  but  the  exceptions  are  very  important.  The 
affection  may  be  uni-  or  bi-lateral :  it  may  be  of  adductors  or  abduc- 
tors, or  both.     The  results,  with  their  reasons,  are  as  follows : — 


Speech. 


Unilateral  Abductor  Paralysis 

Very  little  or  not  at  all  affected,  because  (i)  the 
cords  can  still  approximate  ;  (2)  they  can  still 
be  made  tense  by  the  crico-thyroid. 


1  Even  for  a  student  fairly  well  up  in  anatomy  it  may  be  a  little  difficult  to 
remember  the  action  of  the  laryngeal  muscles,  The  O  in  posterior  may  help  him  to 
remember  that  this  is  the  only  muscle  which  always  and  consistently  Opens  the 
larynx. 


IV 


DISEASES  OF  THORACIC  ORGANS 


77 


Cough,  or  extra- 
ordinary respira- 
tion. 


Respiration. 


In  the  later  phases  of  the  act  unaffected  ;  same 
reasons  as  for  speech.  In  its  first  violent  in- 
spiration possibly  a  little  difficulty  or  stridor, 
because  extraordinary  inspiration  requires  the 
larynx  to  be  as  widely  open  as  possible. 

Ordinary,  unaffected,  because  the  slight  respira- 
tory movement  can  easily  be  affected  by  the 
other  cord. 


Speech. 
Cough. 


Respiration. 


Speech. 


Cough. 


Respiration. 


Speech. 


Bilateral  Abductor  Paralysis 

Still  frequently  unaffected.  Reasons  under  Uni- 
lateral Paralysis. 

In  later  stages  of  the  act  unaffected,  because — 
reasons  above.  In  violent  inspiratory  phase 
probably  considerable  difficulty  or  stridor, 
because  the  lax  cords  may  be  drawn  together 
by  the  draught  of  air,  and  completely  close  or 
seriously  narrow  the  aperture  of  entrance. 

Ordinary,  probably  unaffected,  but  may  be  occa- 
sional severe  dyspncea.  Reasons  under  In- 
spiration of  Cough. 

Unilateral  Adductor  Paralysis 

Probably  unaffected,  because  the  tensor  is  still 
sufficient  to  put  the  cord  in  a  vibratory  condi- 
tion. Hence  a  further  deduction  may  be  made, 
that  if  the  voice  is  altered,  and  only  unilateral 
adductor  paralysis  seen,  the  probabilities  are  in 
favour  of  a  source  for  the  paralysis  high  up, 
before  the  superior  laryngeal  nerve  is  given  off. 

In  later  explosive  phase  probably  weakened, 
because  the  air  begins  to  escape  past  the  lax 
cord  as  soon  as  pressure  increases  in  the  ex- 
piratory effort.  Extraordinary  inspiration 
unaffected. 

Unaffected  to  any  appreciable  degree,  because  air 
can  get  freely  in,  and  the  exit  aperture  is  so 
little  increased. 

Bilateral  Adductor  Paralysis 

Even  now  may  be  unaffected  materially  except 
for  shortness  of  breath  through  loss  of  expira- 
tory control,  because — vide  argument  above  in 
unilateral  trouble,  which  still  holds  good. 


78 

Cough. 

Respiration. 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Later  explosive  stage  almost  nugatory,  because 
air  now  escapes  very  freely  directly  any  excess 
of  pressure  behind  is  produced  by  expiration. 
Extraordinary  inspiration  unaffected ;  aperture 
of  entrance  very  free. 

Probably  a  little  quickening  of  respiration,  because 
of  the  loss  of  control  over  expiration,  so  that 
air  escapes  too  freely. 


Speech. 


Cough. 
Respiration. 


Total  Laryngeal  Paralysis 

May  even  now  be  nearly  perfect  as  regards  tone, 
but  shortness  of  breath  will  be  noted  in  con- 
tinuous speaking,  because — if  the  tensors  have 
escaped  they  are  still  sufficient,  or  nearly  so, 
for  tone  in  single  words,  but  adductor  paralysis 
will  cause  shortness  of  breath  {vide  above). 
If  voice  is  quite  lost,  and  tensors  also  para- 
lysed, we  are  justified  in  diagnosing  a  central 
lesion  in  the  medulla  affecting  both  roots. 

Non-explosive  and  nugatory,  because  of  adductor 
paralysis.  Inspiratory  phase,  possibly  dyspnoea 
and  stridor,  because  of  adductor  paralysis. 

Ordinary,  as  in  all  the  others  may  still  be  unaf- 
fected for  the  reasons  above. 


N.B. — An  opposite  and  complementary  line  of  reasoning  may 
be  applied  to  spasms  of  the  larynx,  which  are  much  rarer  and  only 
in  laryngismus  stridulus  seen  to  perfection. 

Into  the  actual  causes  of  these  paralyses  I  do  not  propose  to  go 
very  deeply  here ;  a  few  will  be  noted  below  under  Tumours  of  the 
Thorax,  and  the  subject  will  be  apparent  again  in  the  nervous 
section.  The  following  outline  classification  is,  however,  useful; 
it  is  mainly  after  Sir  F.  Semon  {B.  M.  J.^  January  i,  1898),  but 
rearranged : — 


Functional. 


Toxsemic. 


So-called  hysterical. 


'  Lead,     arsenic,     and 
possibly  other 

X  metals.  Diphtheria, 
typhoid,  rheuma- 
tism, etc. 


IV 


DISEASES  OF  THORACIC  ORGANS 


79 


Organic. 


Primary  disturbance  in 
the   central   cells    of-| 
medulla  or  cord. 


Primar}'  disturbance  in  j 
the  nerve  trunk.         1 


Traumatism. 


Bulbar  paralysis. 

Tabes  dorsalis. 

Disseminated  scle- 
rosis. 

Haemorrhage. 

Softening.  Tumours 
of  medulla. 

Such  cases  of  the 
toxic  group  as 
have  ended  in  per- 
manent destruc- 
tion. 

Pressure  of  aneur- 
ysms, malignant 
tumours,  inflam- 
matory thickening 
(pleural,  pericar- 
dial, meningeal). 

Syphilitic  processes 
similarly  situated 
to  inflammation. 

'  Surgical. 
Suicidal. 
Accidental. 
Homicidal. 


The  point  of  greatest  practical  importance  is  to  determine 
whether  a  given  paralysis  is  organic  in  origin,  with  practically  no 
chance,  or  functional,  with  a  fair  chance,  of  recovery.  For  the 
toxsemic  group  of  functional  cases  the  great  point  is  to  be  aware 
of  their  existence,  and  should  paralysis  be  discovered  a  history  of 
previous  or  coexistent  illness  must  be  carefully  inquired  for,  and  its 
possible  treatment  by  metallic  drugs  investigated.  The  affection 
itself  has  no  distinguishing  features,  though  it  may  be  expected  to 
be  of  a  bilateral  type  owing  to  its  origin  in  circulating  toxins. 

For  the  so-called  hysterical  paralyses  the  following  points  are 
probably  sufficient : — 

1.  The  patient  will  come  mth  a  predominant  complaint  of 
loss  of  voice. 

2.  Close  physical  examination  will  reveal  no  gross  organic 
lesion,  but  will  probably  show — 


8o  DIFFERENTIAL  DIAGNOSIS  chap. 

3.  Other  features  of  nervous  instability. 

4.  The  sex  will  probably  be  female. 

5.  The  age  will  usually  be  under  thirty. 

6.  The  type  of  paralysis  will  be  adductor  and  tensor,  the 
combination  of  the  two  indicating  a  cerebral  origin,  which  this 
undoubtedly  owns. 

As  no  danger  (of  asphyxia  at  least)  can  arise  from  adductor 
paralysis,  vide  table  for  reasons,  the  mental  association  of  this  form 
with  the  usually  good  prognosis  in  hysteria  may  help  the  student 
to  remember  the  clinical  fact  that  by  far  the  majority  of  cases  of 
adductor  paralysis  are  functional,  while  a  much  greater  proportion — 
in  fact,  all  cases  of  abductor  paralysis — are  of  grave  and  probably 
very  serious  import. 

PNEUMOTHORAX 

Is  a  condition  in  which  air  in  the  sac  separates  the  two  layers 
of  the  pleura ;  this  may  occur  either  over  the  greater  part  or  whole 
of  the  lung,  or  over  much  smaller  areas  limited  by  previous  ad- 
hesions. It  is  a  condition  easily  liable  to  be  overlooked  or  mis- 
understood, and  yet  of  frequent  occurrence,  so  that  it  is  well  we 
should  understand  the  principles  of  its  natural  history  and 
mechanism,  which  are  not,  I  think,  sufficiently  clearly  set  forth 
in  most  text-books. 

In  origin,  then,  the  gas  must  be  : — 

I.  Admitted  from  without.  Traumatism. 


Surgical  procedures. 

External   fistula  opening  into  sac 


(rare). 

2.  Developed  in  situ.  From  decomposition  of  a  pleural 

effusion  (also  rare). 

3.  Admitted  from  within.  (Esophagus  (cancer,  etc.) 
(a)   Bursting    of    a    gas -holding     Stomach  (ulcer,  cancer,  etc.) 

viscus    or    cavity    other    than      Subdiaphragmatic  abscess.        I  ^ 
pulmonary. 

{b)  Laceration  of  visceral  pleura     Phthisis  (most  commonly), 
and  lung.  Abscess  or  gangrene. 

Emphysema. 
Violent  respiratory  efforts  in  healthy 

lungs  (very  rare). 
Penetration  of  broken  bone  through 
pleura. 


IV  DISEASES  OF  THORACIC  ORGANS  8i 

Admitting  that  the  condition  exists,  the  diagnosis  of  the  source, 
according  to  the  above  table,  presents  but  few  difficulties.  In  the 
first  group,  "Admitted  from  without,"  both  the  cause  and  the 
condition  are  obvious,  and  require  no  discussion.  In  the  second 
group,  "Developed  i7i  situ^"  the  pleural  effusion  will  probably  have 
already  attracted  attention ;  the  smell  of  a  little  fluid  withdrawn  by 
aspiration  will  leave  no  doubt  about  decomposition  :  such  cases 
are,  however,  extremely  rare,  and  our  further  analysis  will  be  partly 
applicable  to  them.  In  group  3  [a)  the  previous  symptoms  will  prob- 
ably have  made  the  source  clear  if  the  pneumothorax  be  discovered, 
as,  indeed,  they  will  also  probably  have  done  in  group  3  (b),  but  it  is 
especially  to  this  last  group  that  our  argumentative  analysis  applies 
for  the  estimation  of  the  occurrence  of  the  accident. 

We  must  first  claim  one  or  two  postulates  which  are,  I  think, 
justifiable  :— 

Postulate  I.  That  the  pleura  must  be  healthy  (or  at  least  not 

adherent).      Over  the  area  of  separation  this  must  be  true, 

except  under  conditions  of  gaseous  pressure  too  high  to 

take  into  clinical  consideration. 
Postulate  2.   If  the   pleura   be   healthy  or    non-adherent,    the 

admission  of  air  to  its  cavity  must  allow  of  some  collapse 

of  the  underlying  portion  of  the  lung. 
Postulate  3.  This  collapse  must  diminish  (it  may  be  in  slight 

degree)  the  utility  of  the  affected  lung. 
Postulate  4.   Laceration  of  healthy  pleura  must  be  attended  by 

some  pain  if  consciousness  is  still  present. 
Postulate  5.  (Not  quite  so  obvious,  but  justified,  I  believe,  by 

post-mortem   experience.)      The   opening  into  the   pleura 

must  be  {a)  a  round  hole ;  or  {p)  a  valvular  rent ;  or  (c)  a 

slit  more  or  less  irregular. 
Postulate  6.  That  the  admission  to  the  healthy  pleura  of  air  or  any 

foreign  material  will  cause  cough  of  greater  or  less  severity. 

Granted  these  postulates,  we  may  divide  the  immediate 
symptoms  of  the  occurrence  of  pneumothorax  into  the  inevitable  or 
constant,  and  the  quasi-accidental  or  variable. 

The  Inevitable  or  Constant  are : — 

I.   Cough. — This  is,  in  fact,  the  actual  cause  of  the  accident,  by 
the  increased  air  pressure  it  produces  in  the  lung ;   so 
while   usually  preceding   pneumothorax  it   will   certainly 
.  continue  after  it,  except  in  cases  of  sudden  death. 

G 


82  DIFFERENTIAL  DIAGNOSIS  chap. 

2.  Pain  in  the  side. — Must  be  present  by  postulate  4.     It  is 

usually  sufficient  to  attract  attention,  but  may  be  so  slight 
or  so  mixed  up  with  other  discomfort  as  only  to  be  found 
by  leading  questions. 

3.  Shortness  of  breath  {vide  under  Quasi-Accidental). 

The  Quasi- Accidental  or  Variable  Sympto7ns  are  really  only  one, 
viz.  shortness  of  breath  or  dyspnoea  (the  quickened 
pulse,  the  collapse,  the  sweating,  etc.,  are  merely  variable 
concomitants  of  the  amount  of  asphyxia).  This  short- 
ness of  breath  may  be  so  slight  as  to  be  quite  unnoticed,  or 
may  be  so  severe  as  to  lead  to  death,  appalling  in  its 
suddenness,  with  every  conceivable  degree  between  the 
two.  For  the  primary  explanation  of  the  degree  we  must 
draw  a  distinction  between  the  symptoms  setting  in 
immediately  with  the  accident,  and  those  which  develop 
in  the  course  of  a  little  time.  For  that  which  comes  on 
at  once,  one  quite  sufficient  explanation  is  obvious,  viz. 
the  share  in  aeration  of  the  blood  previously  taken 
by  that  portion  of  the  lung  now  collapsed  and  useless. 
That  which  arises  in  continuance  of  the  primary  trouble 
may  own  this  same  explanation,  but  probably  in  associa- 
tion with  another,  viz.  the  possible  valve-like  action  of 
the  torn  pleura  allowing  an  inspiratory  pumping-in  of  air 
to  the  sac,  but  preventing  expiratory  escape,  so  that  more 
and  more  healthy  lung  is  allowed  or  forced  to  collapse ; 
this  may  go  on  to  a  degree  incompatible  with  life,  or  by 
the  establishment  of  pressure  and  tension  equilibrium  it 
may  remain  stationary,  life  being  still  possible.  In  all 
cases  and  under  all  circumstances  the  ultimate  degree  of 
shortness  of  breath  has  then  the  above  foundation,  viz. 
tlie  previous  uiility  of  the  collapsed  area. 

The  physical  signs  of  pneumothorax,  per  se  and  apart  from  the 
disease  causing  it,  may  be  naturally  divided  into  (a)  those  found  over 
the  area  of  separation  ;  (b)  those  observed  elsewhere. 

{a)  The  former  will  be : — 

On  iilspection. — Nil,  unless  a  large  area  of  lung  be  collapsed, 
when  that  side  of  the  chest  may  be  a  little  sunken,  and 
probably  deficient  in  m.ovement. 


IV  DISEASES  OF  THORACIC  ORGANS  83 

On  palpation. — Nil,  unless  the  opening  into  the  sac  be  a  free 
one,  when  increase  of  tactile  vocal  fremitus  may  be 
appreciated,  owing  to  the  freer  conduction  of  aerial 
vibrations  with  a  resonating  chamber. 

On  percussion. — Hyper-resonance,  owing  to  the  air  coming  into 
immediate  contact  with  the  chest  wall,  and  so  allowing 
unusual  vibratory  opportunities. 

On  auscultation. — The  signs  will  vary  from  tubular  breathing 
with  amphoric  resonance — if  the  opening  be  patent — to 
complete  silence  when  the  lung  is  collapsed,  and  the 
opening  a  mere  slit,  so  that  the  air  pressure  in  the  pleura 
prevents  the  lung  from  expanding. 

{b)  The  latter  refer  to  (i)  the  increased  work  thrown  on  the 
still  functionating  area  of  lung,  leading  to  increased  loudness  of  the 
breath  sounds  previously  heard,  of  whatever  nature;  (2)  the  dis- 
placement of  the  heart's  apex  beat,  which  may  be  much  or  little, 
right  or  left,  according  to  the  amount  and  side  of  the  collapsed 
area  of  lung;  (3)  frequency  of  pulse  and  severity  of  asphyxial 
symptoms,  dependent  as  before  on  the  previous  utility  of  the  portion 
of  lung  now  hors  de  combat^  and  possibly  in  some  degree  on  the 
cardiac  dislocation. 

The  sequelce  and  subsegimit  history  of  a  case  of  pneumothorax 
depend  upon  the  admission  to  a  living  serous  membrane  of  foreign 
material.  If  this  is  merely  aseptic  air,  and  the  opening  is  such  as 
can  readily  be  healed,  recovery  is  likely  to  be  complete  with  the 
restoration  of  the  status  quo  a?zte.  If  it  be  tubercular  or  septic,  it  is 
almost  inevitable  that  pleurisy  of  a  corresponding  type  shall  arise, 
with  its  appropriate  symptoms. 

With  this  analysis,  the  diagnosis  of  pneumothorax  can  hardly 
require  further  discussion,  bearing  in  mind  that  it  always  occurs 
suddenly  as  an  acute  episode  in  health  or  chronic  disease.  It  is, 
however,  somewhat  frequently  assumed  that  the  condition  may  be 
mistaken  for  'a  pathological  cavity  in  the  lung.  When,  as  is 
frequently  the  case,  the  two  coexist,  diagnosis  is  difficult,  I  admit, 
and  probably  immaterial ;  but  under  other  circumstances  the  two 
offer  more  contrasts  than  likenesses,  as  may  be  seen  by  comparing 
the  above  with  the  following : — 


84  DIFFERENTIAL  DIAGNOSIS  chap. 

INDICATIONS  OF  A  PULMONARY  VOMICA 

On  inspection.  Sinking  in   of  chest  from  the  old  fibroid  disease 

which  remains  from  the  original  trouble  that 
caused  the  excavation. 

On  palpation.  Increased    T.V.F.    from    the    consoHdation    sur- 

rounding the  cavity,  and  from  the  resonance 
of  the  chamber. 

On  percussion.  Dulness  and   increased  resistance,  again   arising 

from  induration  and  consolidation  around  the 
cavity. 

On  auscultation.  Tubular    breathing    with     amphoric     resonance, 

frequently  adventitious  sounds  of  the  nature 
of  rales,  and  clicky  or  resonating  crepitations  ; 
the  former  arising  in  and  from  the  cavity,  the 
latter  from  the  fluid  in  it  and  from  the  consoli- 
dating catarrhal  mischief  going  on  around  it, 
so  that  their  absence  is  a  good  sign  as  indicat- 
ing inactivity  of  disease  or  its  obsolescence. 

These  are  the  signs  usually  ascribed  to  a  vomica  in  the  lung, 
and  the  reasoning  is  sound  as  far  as  it  goes,  because  chronic 
phthisical  processes  (tubercular  or  non  -  tubercular,  vide  below, 
Fibroid  Phthisis)  are  far  and  away  the  commonest  causes  of  these 
excavations.  But  even  with  this  causation  there  are  two  or  three 
conditions  that  must  be  fulfilled  before  the  signs  will  be  present  in 
typical  form:  (i)  it  must  be  fairly  superficial  to  prevent  its  appro- 
priate signs  and  sounds  being  overwhelmed  by  those  of  overlying 
healthy  or  diseased  lung ;  (2)  it  must  be  of  fair  size,  at  least  as  large 
as,  say,  a  nut,  to  cause  amphoric  echo  ;  and  (3)  it  must  communicate 
by  a  patent  opening  with  a  bronchus  to  allow  access  of  air.  The 
two  acute  processes,  viz.  abscess  and  gangrene,  which  may  produce 
rapid  excavation  of  the  lung,  are  by  their  very  acuteness  sufficiently 
distinguished,  qua  excavation,  from  tubercular  mischief. 

N.B,—\\,  is  advisable,  or  even  imperative,  in  doubtful  cases  of 
excavation,  to  listen  to  the  chest  actually  while  the  patient  is  coughing^ 
as  well  as  to  note  alterations  in  signs  after  a  cough,  because  the 
tube  or  tubes  leading  to  the  cavity  may  be  blocked  with  material 
only  to  be  removed  by  coughing. 

PHTHISIS 

"An  assemblage  and  progression  of  symptoms  associated  with 
and  dependent  upon  the  ulcerative,  or  suppurative,  destruction  of  a 


IV  DISEASES  OF  THORACIC  ORGANS  85 

more  or  less  circumscribed  non-malignant  deposit  in  the  lungs," 
was  the  late  Sir  Andrew  Clark's  definition  of  the  disease,  and  I  do 
not  think  a  better  one  could  be  devised,  although  it  excludes 
miliary  tuberculosis,  for  it  is  wide  enough  to  embrace  all  the  non- 
tubercular  chronic  destructions  of  the  lung  which  are  associated 
anatomically  with  suppuration  and  ulceration.  Both  before  and 
since  the  enunciation  of  this  definition  an  enormous  amount  of 
literature  has  appeared  containing  exhaustively  detailed  descrip- 
tions of  the  anatomical  results  of  phthisis  in  the  lung,  and 
classifications  of  the  disease  of  such  endless  variety,  that  the 
student  of  the  subject  must  get  confused  in  trying  to  get  an 
intelligent  idea  of  the  whole  of  it ;  for  under  such  a  weight  of 
exposition  he  is  in  great  danger  of  losing  sight  of  that  unity  of 
principle  with  diversity  of  result  which  underlies  and  explains  the 
varying  aspects  of  phthisis  and  chronic  diseases  of  the  lungs.  It 
is  to  this  unity  of  principle  that  I  wish  to  draw  special  attention, 
with  a  few  brief  notes  on  the  results  and  conclusions. 

The  frequency  of  tubercular — as  compared  with  all  other  forms 
of — chronic  irritation  and  destruction  of  the  lung,  and  the  special 
anatomical  results  of  this  special  form,  have  led  to  a  tendency  to 
view  inflammation  in  the  lung  as  always  something  special,  with 
special  laws  of  its  own.  Such  a  view  is  erroneous  and  misleading, 
and  the  first  great  principle  in  our  present  subject  is  that  the  lungs 
offer  no  exception  to  the  rules  that  govern  the  processes  of  so- 
called  inflammation,  as  it  occurs  amongst  vascular  tissues  anywhere 
in  the  body.  These  processes  we  must  briefly  indicate  in  a  series 
of  paragraphs : — 

1.  The  collective  phenomena  known  by  the  name  of  inflamma- 
tion are  the  invariable  result  of  a  locally  acting  (not  necessarily 
locally  produced)  irritant  of  any  kind  whatever^  provided  this  be  not 
sufficiently  severe  to  kill  the  tissues  outright ;  and  then,  be  it 
remembered,  the  processes  go  on  in  the  surrounding  living  tissue, 
the  dead  mass  sharing  in,  or  being  the  efficient  cause  of,  the 
irritation. 

2.  The  first  phenomenon  is  interference  with  the  freedom  of 
circulation  through  the  part,  a  coincident  out-soaking  of  fluid,  and 
the  appearance  in  the  area  of  numbers  of  small  round  cells.  The 
majority  of  these  cells  are  of  feeble  vitality,  if  not  actually  dead, 
representing  as  they  do  to  a  large  extent  the  dead  and  wounded  in 
the  fight  between  invaders  and  defenders.  The  tissues,  too,  in  and 
near  which  the  fight  is  going  on,  suffer  in  vitality  from  the  disturb- 
ance  in   their  normal  circulatory   refreshment ;  this  is  the  functio 


S6  DIFFERENTIAL  DIAGNOSIS  chap. 

/^sa    of   inflammation,   whether    in    mesoblastic   or   epiblastic   ele- 
ments. 

3.  Paragraph  2  represents  the  destructive  phase  of  inflamma- 
tion. It  may  reach  any  degree  of  intensity^  from  the  microscopic-in- 
quantity-but-identical-in-quaUty  of  the  heahng  of  an  aseptic  wound 
up  to  the  quarts  of  pus  and  sloughing  of  septic  cellulitis ;  and  it 
continues  in  the  immediate  neighbourhood  of  the  irritant  so  long 
as  this — or  its  products — remains  in  such  a  condition  and  position 
as  to  come  in  contact  with  irritable  tissues. 

4.  Following  this,  as  the  defenders  locally  or  generally  get  the 
upper  hand,  comes  the  reparative  phase  in  which  granulation  tissue 
is  formed,  consisting  of  new  nucleated  cells  (the  precise  origin  of 
these  and  of  pus,  though  perhaps  important,  has  no  bearing  on  our 
present  purpose),  endowed  with  vitality  because  of,  and  in  propor- 
tion to,  their  proximity  to  supplies  of  nutriment  in  the  shape  of 
newly-formed  blood  capillaries  and  intercellular  lymph  spaces. 

5.  Following  granulation  tissue  comes  the  formation  of  fibrous 
or  scar  tissue,  which  possesses  primarily  some  peculiar  properties : 
(a)  it  is  practically  non- irritable,  hence  should  the  irritant  still 
remain  active  in  situ^  it  serves  to  shut  it  ofl"  from  its  field  of  opera- 
tion on  irritable  tissues,  and  eventually  causes  its  death  by  isola- 
tion ;  ib)  though  poor  in  vitality  itself,  it  is  not  irritating  to  healthy 
tissues,  and  has  no  tendency  like  dead  material  to  cause  a  spread 
of  inflammation  ;  {c)  it  is  extensile  and  contractile,  almost  mechanic- 
ally so,  so  to  speak,  very  different  in  these  qualities  from  naturally 
existing  fibrous  tissue,  exhibiting  either  quality  to  an  extreme  degree, 
unbalanced  by  intermingled  muscular  fibres ;  id)  though  in  general 
it  is  produced  in  an  amount  which  is  simply  reparative,  it  is  occa- 
sionally liable  to  excessive  growth,  as  is  seen  in  false  keloid  and  in 
some  thickened  pleura. 

6.  The  dead  material  that  arises  as  the  result  of  the  destructive 
phases  of  inflammation,  if  left  i7i  situ  and  isolated  by  scar  formation, 
and  if  it  does  not  become  the  seat  of  a  fresh  development  of 
irritating  energy  (septic  microbes,  etc.),  has  a  tendency  to  dry  up 
and  be  converted  into  cheesy  material,  and  ultimately  into  a  cal- 
careous mass  by  the  deposition  of  lime  salts. 

7.  The  two  phases  of  inflammation — the  destructive  and  the 
constructive — must  go  on  so  long  as  the  irritant  remains  in  contact 
with  irritable  tissues.  The  fight  must  always  be  to  the  death  or 
impotency  of  the  tissues,  or  of  the  irritant.  Hence  in  the  case  of 
a  living  and  propagating  irritant  (microbes)  it  may  be  prolonged 
indefinitely ;  the  microbes  striving,  and,  alas !  too  often  with  over- 


IV  DISEASES  OF  THORACIC  ORGANS  87 

whelming  success,  to  cause  destruction,  the  tissues  as  continuously, 
but  with  indifferent  success,  to  efface  their  enemies  by  scar 
formation. 

8.  From  a  given  primary  focus  inflammation  may  spread  by  (a) 
direct  continuity  as  the  irritant  extends  its  area  of  influence  wider 
and  wider  (this  method  of  extension,  if  of  any  distinct  degree,  is 
almost  conclusive  proof  of  microbic  invasion,  for  a  simple  mechani- 
cal irritant  cannot  spread ;  a  non-reproductive  chemical  one  would 
rapidly  become  neutralised  by  combination  ;  and  it  is  only  by  direct 
multiplication  of  the  microbe,  or  by  the  continued  production  of 
toxins,  toxicogenic  zymins,  etc.,  that  we  can  understand  the  widening 
area  of  irritation) ;  (d)  mechanical  transference  of  the  irritant  to 
other  points,  either  by  the  blood  stream  or  per  lymphatic  channels, 
or,  especially  in  the  lungs,  by  air  currents  or  mere  mechanical 
dropping  under  the  influence  of  gravity  into  parts  which  are  for 
the  time  being  lower  than  the  original  focus. 

These  are  the  essential  principles  of  inflammation  wherever 
occurring,  undeviating  in  their  action,  only  modified,  not  obscured 
or  fundamentally  altered,  by  the  nature  of  the  invading  irritant  and 
the  elementary  anatomical  details  of  the  organ  attacked. 

Of  the  modifications  introduced  by  the  nature  of  the  irritant,  we 
must  note  that  in  tubercle  (the  same  is  true  to  a  certain  extent  of 
the  other  infective  granulomata)  there  is  a  special  tendency  to  the 
early  and  rapid  formation  of  a  small  mass  or  nodule  of  granulations 
with  a  vitality  and  cohesion  somewhat  in  excess  of  that  met  with  in 
the  results  of  the  inoculation  of  more  virulent  microbes.  These 
nodules  would  apparently  seem  to  belong  to  the  reparative  side  of 
inflammation,  for  they  do  occasionally — it  is  true  very  rarely — 
become  quite  fibrous  even  in  a  miliary  tubercle,  but  owing  to  their 
low  degree  of  vitality  and  lack  of  capillary  nutrition  they  cannot 
individually  grow  to  any  size  without  caseating  or  softening  down. 
Owang  to  the  great  pertinacity  and  multiplication  of  the  irritant  they 
are,  however,  persistently  produced  in  the  immediate  vicinity  of  the 
original  focus,  and  by  their  union  and  coalescence  may  constitute 
masses  of  caseous  material  as  large  as  the  thumb  or  larger.  If  the 
irritant  be  of  a  more  virulent  type,  the  destructive  phases  of  inflam^- 
mation  are  more  prominent,  with  suppuration  and  tissue  death 
(microscopic  =  necrosis,  macroscopic  —  gangrene),  and,  possibly,  the 
development  of  foul  smelling  gases  as  the  predominating  processes. 
If  different  irritants  of  different  virulencies  be  at  work  at  the  same 
or  successive  times,  the  results  are  likely  to  vary  according  to  the 
above  sketch,  first  one  and  then  another  becoming  the  predominat- 


88  DIFFERENTIAL  DIAGNOSIS  chap. 

ing  feature  of  the  case,  e.g.  catarrh  followed  by  tubercle,  pneumonia 
by  gangrene. 

Of  the  modifications  introduced  by  the  anatomical  peculiarities  of 
the  lung,  we  have  only  to  note  the  air  passages  with  their  enormous 
area  of  mucous  membrane,  lined  with  epithelium,  to  which  air  must 
necessarily  be  freely  admitted ;  air,  too,  which  cannot  always  be 
filtered  through  nasal  vibrissce,  and  which  consequently  often,  or  even 
usually,  contains  multitudes  of  microbic,  mechanical,  and  chemical 
irritants  of  every  kind.  Hence  we  have  (i)  an  extraordinarily  ex- 
tended frontier  offering  opportunities  of  invasion ;  (2)  the  most 
favourable  opportunities  for  the  accumulation,  in  tubes  through 
which  air  currents  are  feeble,  of  mucus  and  dead  epithelial, 
and  other  cells  (catarrhal  products),  on  which  microbes  may  implant 
themselves  without  opposition,  and  grow  and  multiply  till  they  reach 
irritable  tissues ;  (3)  the  physical  signs  of  such  tubercular  nodules 
or  of  catarrhal  and  pneumonic  products  will  naturally  be  essentially 
identical  in  local  details  over  small  areas,  for  they  all  produce  con- 
solidation or  collapse  of  lung  tissue,  or  sticky  fluid  contents  for  the 
air  tubes ;  it  is  this  which  causes  so  many  difficulties  in  diagnosis. 

We  may  now  apply  these  principles  and  their  modifications  to 
explain  the  correlated  pathology  of,  and  the  adjectives  applied  to,  the 
varieties  of  phthisis. 

Pneumonic  Phthisis 

This  term  may  be  used  to  refer  either  to  the  amount  of  con- 
solidation of  the  lung,  or  to  the  clinical  history  of  the  case,  resem- 
bling at  some  period  of  its  course  a  pneumonia  (croupous  or 
catarrhal).  In  the  former  case  we  have  the  tubercular  nodules 
rapidly  forming  and  coalescing  (scrofulous  or  acute  pneumonic 
phthisis  of  authors)  until  large  areas  are  involved,  giving  the 
physical  signs  of  a  pneumonia,  but  without  the  definite  limited 
symptoms  of  that  trouble ;  the  softening  of  the  masses  will  add 
still  further  likeness  to  the  resolution  stages  of  ordinary  pneumonia. 
For  the  latter  signification  of  the  term,  i.e.  a  clinical  history  re- 
sembling that  of  a  pneumonia,  it  is  a  common  enough  event  for  the 
tubercular  nodule  to  cause  an  inflammation  of  a  non-tubercular 
nature  to  surround  the  original  focus  with  consolidation  (tuberculo- 
pneumonic  phthisis  of  authors),  and  this  may  occur  at  any  period 
of  the  progressive  destruction.  In  both  these  cases  the  tubercular 
bacilli  are  the  original  irritating  invaders.  But  another  common 
sequence  is  the  primary  invasion  of  the  pneumococcus  (croupous) 
or  of  less  definite  microbes  (catarrhal),  causing  a  wide-spread  con- 


IV  DISEASES  OF  THORACIC  ORGANS  89 

solidation  or  pneumonia,  and  in  the  weakened  tissues  and  dead 
material  thus  produced  the  specific  tubercle  bacilli  find  a  favour- 
able nidus  for  growth,  and  proceed  more  or  less  rapidly  to  con- 
tinue the  mischief  after  the  acute  symptoms  of  the  original 
invasion  have  subsided.  This  sequence  of  events  explains  the  term 
catarrhal  phthisis,  though  the  term  might  equally  well  be  applied  to 
the  ordinary  cases  of  not  very  acute  tuberculosis  of  the  lung  in 
vrhich  large  areas  are  not  simultaneously  solidified. 

Fibroid  Phthisis 

This  term  includes  all  varieties  of  chronic  lung  destruction,  of 
whatever  nature,  in  which  the  reparative  or  scarring  phases  of 
inflammatory  reaction  have  reached  a  considerable  degree  and  extent. 
Inasmuch  as  the  bacillary  or  simple  irritant  invasion  is  entirely 
a  matter  of  accident,  we  have  the  following  easily  understood 
varieties  : — 

Tubercular.   Another  name  or  v>'ay  of  expressing  a  ver}^  chronic 
case  of  tubercular  phthisis,  in  which  the  fight  being  a  pro- 
longed one,  the   scarring  is  very   evident.        (The  term 
must    obviously  be    also    applicable    to    cases    of   cured 
phthisis.) 
Tuberculo-fibroid.   Nearly  the  equivalent  of  the  first  variety,  only 
that  subsequent  to  the  tubercular  scarring  other  irritants 
continue  the  inflammatory  reaction  and  healing. 
Fibre-tubercular.   In  which  the  primary  scarring  is   due  to  in- 
definite bacillary  or  even  mechanical  (pneumonokoniosis, 
stonemasons'  or  coalminers',  etc.,  lung)  irritants,   and  on 
the    weakened    tissues    the    tubercle    bacillus    makes    a 
descent,    and     continues    the    destruction  -  with  -  healing 
processes. 
Fibroid.   A  condition  of  fibrosis  of  the  lung,  starting  as  above 
(most  commonly,  perhaps,  from  an  unresolved  pneumonia 
or  bronchopneumonia),   but   in  the  production   of  which 
the  tubercle  bacillus  never  at  any  time  plays  any  part. 
N.B. — Post-mortem  experience  would  almost  lead  me  to  believe 
that  in  any  of  these  cases  the  scar  may  take  on  a  keloid-like  exten- 
sion, independent  of  obvious  irritation. 

HEMORRHAGIC    PHTHISIS 

When  haemorrhage  of  noticeable  extent  occurs  as  the  result  of 
"ulcerative  destruction  of  the  lungs,"  the  blood  may  either  coagu- 


90  DIFFERENTIAL  DIAGNOSIS  chap. 

late  in  situ  round  the  focus,  or  it  may  also  be  mechanically  carried 
into  distant  air  tubes  and  alveoli.  The  ulceration  may  or  may  not 
be  due  to  the  action  of  tubercle  bacilli ;  in  the  former  case,  extrava- 
sated  blood  is  likely  to  be  more  or  less  impregnated  with  the  bacilli, 
and  in  proportion  as  it  is  impregnated  it  acts  locally  or  at  a  distance, 
like  a  laboratory  plate  culture,  causing  a  rapid  multiplication  of  the 
points  of  infection.  (This  is  the  old  phthisis  ab  hcemoptoe.  The 
older  pathologists  did  not  recognise,  as  we  now  do,  that  the  bacilli 
were  there  before  the  haemorrhage,  and  that  it  is  only  their  exten- 
sion which  is  due  to  the  bleeding.)  In  the  latter  case,  when 
tubercle  bacilli  are  not  present,  the  haemorrhage,  qiia  haemorrhage, 
is  harmless  enough,  or,  at  least,  has  to  be  considered  from  a  totally 
different  standpoint  of  causation. 

Miliary  Tubercle 

Is  a  condition  in  which  thousands  of  tiny  nodules  are  scattered 
through  the  lungs  (and  other  organs,  liver,  spleen,  etc.,  including 
tubercular  meningitis),  and  only  requires  notice  here  to  insist  upon 
the  fact  that  it  is  never  a  primary  form  of  attack  fro?n  without  of  the 
tubercle  bacillus.  It  invariably  arises  from  some  caseous  or  softening 
tubercular  ^  focus  within  the  body,  the  bacilli  being  carried  thence 
by  lymph  or  blood  stream.  This  focus  can  always  be  found  by  a 
sufficiently  close  search  on  the  post-mortem  table. 

Diagnosis  of  Pulmonary  Tuberculosis 

From  the  above  consideration  of  the  pathology  of,  and  anato- 
mical changes  in,  chronic  and  even  acute  pulm.onary  disease,  it 
will  be  seen  that  an  accurate  and  exact  diagnosis  of  their  causa 
causans  is  not  to  be  obtained  by  physical  signs  alone.  All  such 
affections  are,  or  may  be,  indifferently  associated  with  crepitations, 
rales,  and  rhonchi,  and  with  consolidation  of  small  or  large  areas  of 
lung,  with  or  without  signs  of  pleuritic  involvement.  We  may  be 
inclined  in  one  direction  by  the  localisation  of  these  morbid 
phenomena  to  an  apex  or  to  a  base,  and  led  in  another  by  their 
universal  distribution  over  the  whole  of  one  or  both  lungs.     The 

^  In  all  that  relates  to  phthisis  the  terms  ' '  tubercle  "  and  ' '  tubercular  "  are  used  in 
strictly  concomitant  association  with  assumed  specific  bacilli.  The  terms  "nodule"  and 
"  nodular  "  are  used  in  their  strict  meaning  of  a  little  lump,  or  referring  to  a  little  lump. 
It  is  the  confusion  in  these  terms  that  has  led  to  much  confusion  in  translating  tl^.e 
meaning  of  the  older  authors,  who  made  tubercle  the  equivalent  of  a  little  lump,  with- 
out reference  to  the  presence  or  absence  of  bacilli,  of  which,  indeed,  they  naturally 
knew  nothing. 


IV  DISEASES  OF  THORACIC  ORGANS  91 

family  history  may  show  a  special  proclivity  to  tubercular  disease.  ^ 
We  must  weigh  the  circumstances  of  occupation  as  affording  0})por- 
tunities  for  pneumonokoniosis ;  we  must  note  with  anxiety  a  failing 
appetite,  with  wasting  and  sweating,  and  carefully  watch  the  pro- 
gress of  our  patient  when  acute  symptoms  (cough,  fever,  haemo- 
ptysis, etc.)  have  subsided.  But  when  all  these  points  have  been 
duly  weighed  in  the  balance,  remembering  that  tubercle  may  pre- 
cede, accompany,  or  succeed  any  other  irritant,  we  shall  still  have 
before  us  the  one  crucial  question,  "Is  the  bacillus  tuberculosis 
present  in  the  expectoration  or  not  ? "  Universal  consensus  of 
opinion  warrants  the  statement  that  if  the  bacillus  be  found,  it  is  at 
any  rate  a  prominent  sharer,  if  not  the  sole  factor,  in  the  production 
of  the  patient's  illness,  so  that  if  we  would  guard  against  disappoint- 
ment in  prognosis  and  errors  in  diagnosis,  the  search  for  the 
microbe  must  be  undertaken  in  every  case  permitting  of  doubt. 
The  most  likely  cases  for  error  and  doubt  are  the  following : — 

(a)  Bronchitis  and  Bronchopneu77ionia  in  Babies  a?id  Young 
Children. — Here  sputum  for  examination  is  practically  unobtainable, 
and  we  must  rely  mainly  on  the  following  considerations : — If  the 
disease  is  simple  in  origin  the  patient  should  get  well  in  from  two 
to  three  weeks,  and  the  improvement  in  the  child  should  correspond 
fairly  w^ell  to  the  clearing  up  of  the  morbid  lung  sounds.  If  the 
child  does  not  rapidly  pick  up  after  this  time,  a  very  careful  search 
must  be  made  for  empyema,  which  very  commonly  develops  and 
retards  convalescence.  Should  no  evidence  of  pleuritic  trouble  be 
found,  and  the  child  still  not  improve,  then  tubercle  must  come 
strongly  under  suspicion,  and  every  system  and  part  of  the  body 
must  be  carefully  examined  for  corroborating  or  contradicting 
evidence.  Pulmonary  tubercle  under  the  age  of  say  ten  or  eleven 
years  is  practically  only  of  one  kind,  viz.  miliary,  or  at  least  very 
widespread,  and  hence  a  wide  area  of  persistent  morbid  phenomena 
will  be  suggestive.  Those  other  unknown  irritants  which  maintain 
a  chronic  catarrhal  condition  have  a  contrary  tendency,  viz.  one  to 
preserve  their  morbid  activity  only  in  one  locaUty,  and  that  usually 
at  the  base.  These  basic  chronic  catarrhs,  especially  if  occurring 
after  a  specific  fever,  such  as  measles,  by  no  means  infrequently 
persist,  and  form  the  origin  of  a  genuine  purely  non- tubercular 
fibroid  phthisis. 

1  Modern  opinion,  in  more  strict  accordance  with  the  bacillary  or  infective  theories 
of  tubercular  processes,  is  inclined  to  attribute  more  weight  to  the  view  of  direct  infec- 
tion by  personal  contact  with  a  sick  relative  or  friend,  or  by  inhalation  of  germ- 
infected  air  of  the  sick-room,  and  less  to  the  mere  possession  of  tubercular  ancestors. 


92  DIFFERENTIAL  DIAGNOSIS  chap. 

(b)  Repeated  attacks  of  "  Cold  and  Cough^''  ivith  slight  symptoms 
of  Mild  Bronchitis. — This  group  of  symptoms  constitutes  the  very 
commonest  history  of  the  commencement  of  an  ordinary  case  of 
phthisis,  and  must,  therefore,  ab  initio.,  arouse  our  strongest  suspi- 
cions. Sputum  may  be  available,  and  may  decide  the  diagnosis  out 
of  hand,  but  it  must  be  remembered  that  even  tubercle  takes  a 
little  time  to  soften  and  ulcerate,  so  that  expectoration  may  be 
unobtainable,  or,  again,  its  examination  may  yield  merely  negative 
results.  We  must  then  proceed  to  carefully  examine  the  lungs  for 
a  small  localised  area  over  which  the  auscultatory  phenomena  are 
not  only  pathological,  but  different  from  the  universally  heard 
rhonchus  of  bronchitis,  and  suggestive  of  consolidation.  Such  are 
commonly,  but  by  no  means  invariably,  found  at  the  apices  of  the 
chest.  They  are  found  frequently  enough  at  the  apex  of  a  lobe,  or, 
in  my  experience,  often  in  the  neighbourhood  of  the  pericardium. 
I  do  not  think  that  a  visible  want  of  expansion  or  altered  percus- 
sion note  is  of  much  use  in  deciding  doubtful  cases.  By  the  time 
they  are  definite  enough  for  observation  the  general  symptoms  have 
rendered  their  aid  superfluous.  I  am  accustomed  to  rely  more 
upon  the  sharpness  of  the  crepitations — "clicky"  is  the  term  I  usually 
apply  to  them — and  a  slight  increase  in  voice  and  expiratory  breath 
sounds.  If  these  go  with  a  pulse  frequency,  and  a  loss  of  weight 
and  appetite  out  of  proportion  to  the  apparent  illness,  I  feel  at  any 
rate  judgment  must  be  suspended,  and  the  case  declared  one  of 
doubtful  and  suspicious  nature,  and  the  more  suspicious,  the 
stronger  the  lead  given  by  the  patient's  history,  whether  family  or 
personal.  These  are  the  cases  that  made  our  predecessors  in 
medicine  divide  their  patients  up  into  constitutional  types  of  liabi- 
lity to  consumption  :  the  blonde,  with  thin  flaxen  hair,  the  brunette, 
with  flushed  cheeks,  the  sprightly  or  ethereal,  the  clumsy  or  scrofu- 
lous ;  their  descriptions  are  still  true  in  the  main,  for  they  were 
founded  on  an  experience  which  is  still  ours. 

(c)  HcE7noptysis. — It  may  be  said  at  once  that  genuine  pulm.onary 
haemoptysis,  and  especially  if  free  or  repeated,  when  found  w^ith  the 
physical  signs  and  symptoms  considered  under  ib\  adds  so  enor- 
mously to  the  probabilities  of  tubercle  as  to  render  diagnosis  nearly 
certain  ;  but  the  symptom  is  so  common  and  so  alarming  to  our 
patients,  that  it  may  be  discussed  at  a  little  greater  length.  We 
have  already  (p.  54)  enumerated  and  briefly  mentioned  the  possible 
causes  of  hsemorrhage,  and  on  p.  152  given  the  diagnosis  between 
haemoptysis  and  hsematemesis.  It  remains  here  to  consider  the 
question  commonly  enough  asked,  "What  do  you  expect  to  hear 


IV  DISEASES  OF  THORACIC  ORGANS  93 

in  the  chest  of  a  patient  who  comes  to  you  complaining  of  '  spitting 
of  blood  ?  '  "  We  may,  I  think,  reply  accurately  enough  by  saying, 
"  If  blood-spitting  is  his  07ily  complaint,  it  is  probable  that  we  shall 
hear  nothing."  The  reasons  for  this  reply  are:  (i)  that  in  a  very 
large  proportion  of  such  cases  the  blood  comes  from  elsewhere  than 
the  lungs — gums,  pharj^nx,  nose,  larynx,  etc. ;  (2)  that  in  again  a 
large  proportion  of  the  cases  in  which  the  blood  does  really  come 
from  the  lungs,  it  is  symptomatic  of  advanced  heart  or  lung  disease, 
which  will  have  given  rise  to  marked  symptoms  previous  to,  and 
different  from,  the  haemorrhage ;  and  (3)  it  is  a  common  experience 
that  we  hear  nothing — not  even  the  crepitations  of  blood  in  the 
bronchioles — in  those  cases  which  time  shows  only  too  clearly  were 
really  cases  of  tubercular  haemorrhage.  In  connection  with  the 
diagnosis  of  the  causes  of  pulmonary  haemorrhage,  I  cannot  conclude 
better  than  by  quoting  a  few  sentences  written  by  Sir  Thomas 
Watson  many  years  ago,  and  which  still  hold  good.  He  says 
(^Lectures  o?i  the  Principles  a7id  Practice  of  Physics^  5th  edition,  187 1): 
"  Cceteris  paribus,  the  disposition  to  pulmonary  hsemorrhage  is  in- 
creased by  whatever  tends  to  diminish  the  capacity  of  the  thorax, 
and  to  compress  the  lungs,  or  the  heart  and  great  vessels.  It  is 
partly  on  this  principle  that  we  may  account  for  the  frequency  of 
haemoptysis  in  persons  with  crooked  spines:  in  tailors  who  sit 
continually  in  a  stooping  posture ;  in  young  women  who  lace  their 
stays  too  tightly ;  and  even  in  those  who  labour  under  dropsy  or 
other  cause  of  distension  of  the  belly."  He  then  quotes  in  full 
detail  a  case  of  vicarious  menstrual  hemoptysis,  and  proceeds :  "It 
is,  however,  a  melancholy  truth  that  capillary  haemorrhage  from  the 
mucous  membrane  of  the  air  passages  is  dependent  in  a  very  large 
proportion  of  cases  upon  incurable  disease — tubercular  phthisis  or 
organic  disease  of  the  heart.  When  haemoptysis  is  thus  actually 
symptomatic  of  tubercular  disease  of  the  lungs,  it  is  liable  to  con- 
siderable variety  in  regard  to  the  period  of  its  first  occurrence. 
There  are  many  persons  in  whom  the  first  attack  of  haemoptysis 
precedes,  even  for  years,  the  primary  symptoms  of  unequivocal 
phthisis.  There  are  others  in  whom  the  first  attack  of  haemoptysis 
is  immediately  followed  by  all  the  signs  which  announce  the  pre- 
sence of  tubercles  in  the  lungs."  He  then  mentions  heart  disease 
and  pulmonary  apoplexy,  and  after  quoting  Andral  to  say  that : 
"  Of  those  individuals  whom  he  had  known  to  spit  blood  at  some 
period  or  other  of  their  lives,  there  was  only  one  in  five  whom  he 
did  not  know  to  have  tubercular  phthisis."  He  deplores  his  in- 
ability to  alter  the  opinion  he  had  long  held  and  expressed:   "That 


94  DIFFERENTIAL  DIAGNOSIS  chap. 

if  from  any  given  number  of  persons  who  have  been  known  to  spit 
blood — excluding  the  streaks  of  bronchitis,  the  rust -coloured  ex- 
pectoration of  pneumonia,  and  injury  to  the  chest — we  subtract 
those  in  whom  that  symptom  was  connected  with  irregularity  in  the 
uterine  functions,  and  those  in  whom  it  was  symptomatic  of  cardiac 
disease,  there  will  be  very  few  indeed  left  in  whose  lungs  the  exist- 
ence of  tubercle  or  other  fatal  disease  may  not  be  confidently 
predicated." 

Except  that  we  do  not  now  regard  pulmonary  tuberculosis  with 
quite  such  a  hopeless  feeling  as  regards  prognosis,  these  statements 
of  Sir  Thomas  Watson  are,  I  think,  as  true  now  as  when  he  wrote 
them. 

(d)  Pneumonia  that  does  not  clear  up  rapidly  after  the  Temperature 
has  fallen. — Here  the  very  fact  that  the  lungs  do  not  clear  up  in, 
say,  three  or  four  weeks,  constitutes  in  itself  proof  that  somethiftg 
other  than  the  pneumococcus  is  at  work.  This  something  may  be 
tubercle  bacilli  or  others  not  yet  sufficiently  identified  (there  is  just 
a  possibility  that  the  lung  tissue — the  soil — of  the  individual  may 
be  peculiarly  weak,  and  allow  well  known  microbes  to  continue  the 
irritation).  Expectoration  is  always  present,  and  can  be  obtained  for 
bacteriological  examination,  so  that  diagnosis  requires  no  further 
remark  beyond  calling  attention  to  the  fact  that  an  unresolved 
pneumonia  is  not  necessarily  at  any  time  tubercular^  but  may  at  any  time 
become  so,  and  is,  therefore,  a  standing  menace  to  its  possessor. 

(e)  Chronic  Bronchitis. —  Vide  below,  p.  98.  Here  I  can  only 
say  sputum  is  again  available,  and  must  be  examined. 

Of  pyrexia  in  these  various  cases  I  have  said  but  little,  as  its 
indications  are  of  dubious  significance.  On  the  one  hand,  it  is 
certain  that  a  slight  rise  of  temperature  (loi  or  less)  in  the  evening 
(especially  with  early  morning  sweating)  is  strongly  suggestive  of 
tubercle  in  those  cases,  as  in  group  (p),  where  the  physical  signs 
are  doubtful;  but,  on  the  other  hand,  it  is  equally  certain  that 
typical  hectic  temperature  (102,  103,  or  104  at  night;  97  to  99  in 
the  morning)  is  due  more  to  septic  processes,  either  with  or  without 
tubercle,  than  to  tubercle  itself,  so  that  in  the  other  groups  we  get 
very  little  assistance  from  thermometric  observations. 

There  is  only  one  other  point  in  phthisis  that  I  propose  to 
mention,  that  is  diarrhoea.  It  is  important  to  remember  that  it 
may  be  due  to  any  of  the  following  : — 

{a)  Simple  dietetic  errors,  from  which  phthisis  is  no  protection. 
Inquiry  into  food  will  possibly  suggest  this  cause. 

(b)  Simple  irritability  of  alimentary  tract,  which  is  very  common 


IV  DISEASES  OF  THORACIC  ORGANS  95 

in  these  patients,  and  may  be  increased  by  swallowing  septic  or 
irritating  matter  which  ought  to  be  expectorated.  The  diagnosis  of 
this  form  can  only  be  made  by  exclusion,  and  by  noting  that  it 
moderates  or  ceases  under  appropriate  treatment,  and  warning 
against  swallowing  sputum. 

(c)  Tubercular  ulceration  of  gut.  The  diagnosis  will  mainly  rest 
on  the  intractability  of  the  diarrhoea,  and  possibly  some  tenderness 
of  abdomen,  together  with  an  exclusive  consideration  of  the  other 
three  conditions. 

[d)  Amyloid  or  lardaceous  disease.  This  generally  admits  of 
easy  diagnosis  from  the  enlargement  of  the  liver  and  spleen,  and 
considerable  quantities  of  albumen  (without  pus)  in  the  urine.  It 
is  very  rare  for  the  intestine  to  be  the  sole  or  even  the  principal 
seat  of  the  deposit.  Should  this,  however,  happen  to  be  the  case, 
it  may  be  difficult  or  impossible  to  differentiate  the  condition  from 
tubercular  ulceration.  In  both  cases  the  patient  will  probably  be 
anaemic  and  cachectic ;  in  both  the  flux  will  be  persistent  and  in- 
tractable. We  may  remember  that  amyloid  degeneration  never 
occurs  in  early  phthisis  before  suppuration  has  been  long  estab- 
lished ;  intestinal  ulceration  may,  on  the  other  hand,  be  a  much 
earlier  feature.  Diarrhoea  from  amyloid  disease,  again,  is  usually 
stated  to  be  entirely  free  from  abdominal  pain,  while  ulceration  is 
frequently  associated  with  colicky  disturbances. 

PNEUMONIA 

Of  the  diagnosis  of  a  well-developed  attack  but  little  needs  to 
be  said.  The  flushed  or  bluish  face,  with  sweat  standing  in  large 
drops  on  the  forehead,  the  working  of  the  alae  nasi,  the  rapid 
breathing,  the  painful  efforts  at  subduing  a  distressing  cough,  makes 
up  such  a  typical  picture  that  we  can  often  diagnose  the  disease  at 
sight  j  and  when  woodeny  dulness  on  percussion  and  tubular  breath- 
ing on  auscultation  are  added,  the  diagnosis  is  complete.  But  there 
are  one  or  two  points  still  that  are  worth  a  little  discussion,  even  in 
an  elementary  work. 

Diagfiosis  in  Early  Stages. — Primary  or  idiopathic  pneumonia  is 
particularly  characterised  by  the  very  sudden  rise  in  the  temperature 
(probably  103  or  104  within  twelve  hours),  and  a  corresponding 
sudden  onset  of  symptoms;  while  the  physical  signs,  being  much 
slower  in  development,  are  still  in  abeyance.  These  symptoms  are 
usually  a  rigor,  or  convulsions  (convulsions  in  children  often  take 
the  position  of  rigors  in  the  adult  as  an  indication  of  severe  invasion 


96  DIFFERENTIAL  DIAGNOSIS  chap. 

by  microbes),  speedily  followed  by  headache  with  intolerance  of 
light,  frequently  enough  delirium,  and  vomiting  of  a  nervous  type, 
i.e.  independent  of  food.  Now  these  are  precisely  the  symptoms 
suggestive  of  an  acute  toxaemia,  or  of  intracranial  inflammation  ; 
and  hence  many  cases  of  incipient  pneumonia  may  hastily  be 
assumed  to  be  something  more  dangerous  than  ultimately  proves 
to  be  the  case. 

Careful  attention  to  the  following  points  may  assist  us  in  form- 
ing an  opinion,  but  for  twenty-four  or  even  forty-eight  hours  it  is 
often  absolutely  impossible  to  make  a  final  diagnosis. 

Inquire  of  the  patient  or  friends  as  to  any  possible  local  source 
of  infection,  such  as  a  wound,  a  boil,  or  an  abscess,  or  even  a  blow 
on  the  head,  and  especially  as  to  any  discharge  from  an  ear ;  the 
throat  and  ears  must  then  be  examined  for  signs  of  septic  mischief, 
and  time  would  not  be  wasted  by  asking  if  the  patient  has  had  the 
opportunity  of  acquiring  an  infectious  disease  from  a  sick  friend. 
If  negative  replies  are  received  to  these  inquiries,  note  the  pulse- 
respiration -temperature  ratio,  vide  p.  35,  which  even  from  the 
commencement  is  very  likely  to  be  markedly  deranged  in  a  case 
of  pneumonia.  Should  the  indications  be  still  undecided,  judgment 
must  be  withheld  temporarily,  until  a  cough  with  expectoration  or 
physical  signs  come  to  our  aid. 

Central  Pneumonia. — It  occasionally  happens  that  a  pneumonia 
develops  in,  and  remains  confined  to,  the  central  part  of  one  base, 
and  thus  the  physical  signs,  even  in  the  later  stages,  are  concealed 
or  ill  developed.  In  such  cases  the  sputum  becomes  a  most  valu- 
able sign,  and  quite  possibly  gives  an  absolutely  decisive  indication ; 
it  is  probably  extremely  sticky,  but  little  aerated  and  non-purulent. 
If  with  these  features  it  is  uniformly  stained  with  blood  pigment, 
we  are  justified  in  saying  that  some  pneumonia  is  present — the 
staining  may  be  of  any  degree  from  rust  to  prune-juice  colour,  and 
the  deeper  it  is,  the  worse  the  outlook. 

Is  Pneumonia  a  Specific  Disease  ? — The  facts  suggesting  such  a 
theory  are : — 

(i)  The  sudden  onset  of  symptoms  before,  and  independently 
of,  the  lung  consolidation. 

(2)  The  sudden  cessation  of  the  symptoms  while  the  consolida- 
tion still  remains. 

(3)  The  definiteness  of  the  phases  through  which  a  typical  case 
of  the  disease  passes. 

(4)  The  undisputed  occurrence  of  small  epidemics,  and  the 
appearance  of  attacks  in  which  the  evidence  of  infection  from  a 


IV  DISEASES  OF  THORACIC  ORGANS  97 

previous  case  is  overwhelmingly  strong  (noticed  in  anxious  wives  or 
mothers  too  closely  attending  their  sick  charges). 

(5)  A  microbe  of  very  definite  character  has  been  pretty  con- 
stantly found  in  sputum  and  lungs  of  typical  cases ;  it  has  been 
isolated  and  cultivated,  and  to  a  limited  extent  has  been  put  through 
the  tests  on  p.  26. 

Nos.  (i)  and  (2)  undoubtedly  prove  to  a  demonstration  that  the 
symptoms  of  pneumonia  are  not  due  to  the  lung  consolidation  as 
such,  while  (5)  offers  a  plausible  explanation  of  them;  and  we  may, 
I  think,  sum  the  matter  up  by  asserting  that  "  One  particular 
microbe  is  capable  of  producing  a  form  of  disease  to  which  the 
term  '  idiopathic  pneumonia '  is  applicable,  but  that  facts  do  not 
prove  that  this  is  the  only  microbe  capable  of  producing  a  set 
of  clinical  phenomena  indistinguishable  from  such  pneumonias." 
Accurate  post-mortem  evidence,  coupled  with  scrupulously  exact 
bacteriological  work,  would,  I  suppose,  clear  up  every  case  and  prove 
its  precise  causation,  but  there  can  be  no  disputing  the  fact  that 
consolidations  of  large  areas  of  the  lung,  coupled  with  symptoms 
indistinguishable  per  se  {i.e.  apart  from  the  clinical  history  of  the 
case  previous  to  their  onset)  from  those  of  an  ordinary  pneumonia, 
do  occur  in  the  course  of  bronchial  catarrh,  of  puerperal,  and  other 
septic  troubles,  and  of  influenza  amongst  many  other  diseases. 
Admitting  this,  it  is  difficult  to  believe  that  the  lung  mischief  is 
necessarily  due  to  diplococcus  pneumoniae,  and  that  we  must  deny 
to  other  pathogenic  organisms — specific  or  common,  known  and 
unknown — this  power  over  the  lung.  Again,  on  the  other  side  of 
the  question,  the  diplococcus  pneumoniae  has  been  found  frequently 
in  morbid  effusions  in  joints  and  elsewhere,  under  circumstances 
strongly  suspicious  of  a  causative  relation,  so  that  it  cannot  be  said 
to  confine  its  attention  to  the  lungs. 

The  only  possible  deduction  from  these  facts  is  to  give  to 
clinical  pneumonia  a  modified  specificity,  perhaps  equal  to  that 
given  to  clinical  diphtheria  (^-v.),  while  denying  to  it  one  so  com- 
plete and  unequivocal  as  that  given  to  measles,  syphilis,  or  scarlet 
fever. 


ACUTE  BRONCHITIS  AND  BRONCHOPNEUMONIA 

The  late  Dr.  Sutton  used  to  teach  that  healthy  children  did 
not  suffer  from  bronchitis.  If  this  be  so,  then  the  zymotics,  poor 
feeding,  and  neglect  are  responsible  for  much  subsequent  disease 
amongst  our   young  population,  for   bronchitis   is  a  very  common 

II 


98  DIFFERENTIAL  DIAGNOSIS  chap. 

disease  in  infants,  and  as  bronchopneumonia  is  a  direct  extension 
of  the  morbid  processes  to  the  bronchioles  and  alveoh,  it  is  a 
common  difficulty  to  decide  whether  a  given  case  shall  be  called 
bronchitis  or  bronchopneumonia.  My  own  opinion  is  that  prac- 
tically all  cases  of  bronchitis  amongst  young  children,  if  severe,  have 
some  degree  of  alveolar  extension,  so  that  from  the  point  of  view  of 
treatment  the  diagnosis  is  of  little  moment,  being  more  of  academic 
or  examinational  interest.  If  dulness  on  percussion  and  tubular 
breathing  are  present  over  localised  areas  they  settle  the  matter  at 
once,  but  as  these  are  easily  obscured  by  non-affected  lung  tissue 
and  the  rhonchi  of  the  bronchitis,  and  as  children  are  awkward  at, 
or  incapable  of,  deep  voluntary  respiration,  I  usually  rely  upon  the 
following  two  features:  (i)  The  Temperature:  if  ioi°  or  over,  it 
points  to  alveolar  extension  ;  if  below  i  o  i  °  and  yet  above  normal,  it 
points  to  uncomplicated  bronchitis  ;  if  markedly  subnormal,  it  again 
points  to  very  dangerous  and  universal  bronchiolar  involvement. 
(2)  Rales  and  crepitations :  if  these  are  so  abundant  as  to  markedly 
predominate  over  the  rhonchi  of  bronchitis,  I  again  assume  that 
bronchopneumonia  is  present.  Dr.  Osier,  in  his  deservedly  popu- 
lar work  on  medicine,  will  not  allow  any  difference  between 
capillary  bronchitis  and  bronchopneumonia.  As  regards  the  nature 
of  the  morbid  process  he  is  obviously  right,  for  one  cannot  draw 
an  imaginary  mathematical  line  between  bronchioles  and  alveoli ; 
but  as  regards  extent  in  area  I  think  he  is  wrong,  and  I  would  define 
bronchopneumonia  as  a  local  (few  or  many  patches),  capillary 
bronchitis  as  a  universal,  extension  of  the  catarrhal  process  to  fine 
tubes  and  alveoli.  This  definition  best  explains  the  undoubted 
difference  in  prognosis ;  capillary  bronchitis  I  regard  as  uniformly 
and  inevitably  fatal,  while  recoveries  from  local  consolidation  are 
numerous  and,  indeed,  the  rule. 


CHRONIC  BRONCHITIS  AND  ITS  ASSOCIATIONS 

It  is  a  very  common  observation  that  one  attack  of  bronchitis 
(irrespective  of  the  nature  of  the  irritant  causing  it)  predisposes  the 
sufferer  to  another.  A  little  consideration  of  the  pathology  of 
inflammation  easily  explains  this.  It  is  almost  inevitable  that,  in  a 
mucous  membrane  that  has  once  been  inflamed  and  shed  a  good 
deal  of  epithelium,  slight  scar  changes,  diminishing  its  vital  resist- 
ance, should  be  left  behind.  Proceeding  further,  if  we  allow 
that   these    changes    (scar    tissue)  will    diminish    the    natural  vital 


IV  DISEASES  OF  THORACIC  ORGANS  99 

elasticity  of  the  tubes,  it  is  easy  to  see  that  with  repeated  attacks 
two  consequences  are  likely  to  follow:  (i)  the  stiffening  process 
will  extend  farther  and  farther  down  the  tubes,  or  become  more 
and  more  marked  in  local  segments  of  them ;  from  this  it  will 
follow  (2)  that  increased  air  pressure,  w^hether  expiratory  or  in- 
spiratory matters  not,  must  be  felt  more  and  more  by  the  smaller 
air  tubes  and  alveoli,  which  were  never  meant  to  stand  such  a  strain, 
and  consequently  yield  to  it,  giving  us  bronchiectasis,  local  or 
general,  and  emphysema.  If  the  lung  trouble  is  of  such  a  nature 
as  to  be  associated  v>'ith  much  scar  tissue,  then  this  may  by  con- 
traction constrict  air  tubes,  leading  to  dilation  above  the  obstruction, 
or  if  it  has  a  distant  point  of  support  its  contraction  may  lead  to  a 
pulling  open  of  tubes.  We  must  not  forget,  too,  that  in  elderly 
people,  at  all  events,  there  is  yet  a  third  factor,  and  an  important 
one,  in  the  production  of  these  degenerative  or  fibrotic  processes ; 
this  is  arterial  degeneration  or  wearing  out  of  arterioles,  with  conse- 
quent imperfect  nutritional  changes  in  fine  tissues.  It  is  a  clinical 
fact  that  an  enormous  numerical  preponderance  of  cases  of  "bron- 
chitis and  emphysema  "  in  persons  over  forty,  say,  have  atheroma 
of  arteries  well  marked,  and  I  believe  the  association  is  causative, 
and  not  an  accidental  accompaniment  of  age.  We  are  thus  led 
by  simple  deductive  reasoning  to  appreciate  the  pathology  and 
occurrence  of — 

The  Pulmonary  Complications  of  Chronic  Bronchitis 

(i)  Brotichiedasis^  of  which  the  principal  diagnostic  features 
are :  large  quantities  of  expectoration,  often  brought  up  in 
mouthfuls  at  a  time,  and  frequently  foetid ;  this  foetor  is  a 
most  important  diagnostic  point  between  bronchiectasis  and 
a  phthisical  cavity,  for  the  latter  never  or  hardly  ever  possesses 
foetid  contents  ;  otherwise  the  physical  signs  of  the  two 
conditions  are  almost  identical. 

(2)  M??iphysema,  of  which  hyper-resonance  or  too  great  an  exten- 
sion of  resonance  is  the  main  sign,  coupled  with  prolonged 
expiration  and  shortness  of  breath  out  of  proportion  to  the 
cardiac  condition  or  the  signs  of  bronchitis. 

(3)  Collapse,  arising  from  constriction  of  a  tube  or  from  plug- 
ging of  it  by  catarrhal  products.  Over  a  collapsed  area  there 
is  likely  to  be  a  little  alteration  in  the  percussion  note — 
dulness  or  woodeny  sound — but  absence  of  breath  sounds 


loo  DIFFERENTIAL  DIAGNOSIS  chap. 

will  be  naturally  the  chief  feature,  and,  possibly,  slight  fine 
crepitus  on  very  forced  inspiration. 

(4)  Hce?noptysis,  from  rupture  of  a  vessel,  either  owing  to  de- 
generation or  to  mechanical  stretching,  or  possibly  to  venous 
distension  in  a  violent  paroxysm  of  coughing. 

(5)  Pleurisy  or  pleuritic  effusion^  arising  from  extension  of  in- 
flammation or  from  passive  disturbance  of  circulatory  ex- 
changes ;  diagnosed  by  a  rub  or  dull  percussion  note  with 
segophony,  etc.  {^ide  below). 

(6)  Bronchopneii77ionia  and  capillary  bronchitis^  arising  from  ex- 
tension of  the  catarrhal  process  to  bronchioles  and  alveoli, 
either  in  an  ordinary  and  direct  manner,  or  by  the  insuffla- 
tion of  the  decomposing  contents  of  a  bronchiectasis. 
These  are  perhaps  the  most  important  complications  of  all, 
for  they  are  very  frequently  the  direct  cause  of  a  fatal 
ending  to  the  case.  Moreover,  tubercular  bacilli  may  suc- 
ceed, by  their  assistance,  in  implanting  themselves  on  the 
weakened  tissues  or  catarrhal  contents  of  the  tubes.  The  on- 
set of  capillary  bronchitis  {vide  definition  above)  is  marked 
either  by  a  prominent  rise  (inflammatory  reaction),  or,  more 
probably,  by  an  equally  prominent  fall,  in  the  temperature  to 
subnormal  (asphyxial  or  exhaustive  decline).  This  alteration 
will  be  associated  with  a  very  marked  exaggeration  of  the 
breathlessness  and  cyanosis,  the  pulse  will  speedily  become 
extremely  frequent,  small,  and  thready,  and  the  patient  will 
rapidly  pass  into  a  condition  of  extreme  danger  from 
asphyxia;  in  true  universal  capillary  bronchitis  he  never 
rallies,  but  cold,  clammy  perspiration  soon  appears,  and 
death  foflows  in  less  than  forty-eight  hours.  The  diagnosis 
of  bronchopneumonia,  when  associated  with  a  smart  febrile 
attack,  does  not  present  any  difficulty;  but  when  we  are 
attending  an  elderly  patient,  the  subject  of  chronic  bron- 
chitis, we  must  be  on  our  guard  to  examine  the  lungs 
pretty  frequently,  as  this  alveolar  extension  often  creeps  on 
in  a  most  insidious  manner  (pleuritic  effusion  may  behave 
similarly,  vide  below),  a  little  extra  cough  and  shortness  of 
breath,  a  little  flushing  of  the  face,  perhaps,  or  sense  of 
weakness  or  exhaustion,  being  the  only  outward  indications 
of  the  mischief,  which  is  most  serious  in  its  result.  If  we  do, 
however,  discover  by  care  such  a  smouldering  danger,  we 
must  not  forget  to  test  the  sputum  for  bacilli,  as  this  is  the 


IV  DISEASES  OF  THORACIC  ORGANS  loi 

common    history   of   tuberculosis    supervening    on    chronic 
bronchitic  trouble. 


PLEURISY  AND  PLEURITIC  EFFUSION 

To  discover  the  mere  presence  of  these  troubles  is  usually  easy; 
to  estimate  aright  their  clinical  significance  is  far  more  important 
and  difficult. 

Acute  Pleurisy 

Sympto??is  aytd  Physical  Signs. — Of  the  diagnosis  of  the  presence 
of  acute  pleurisy  I  shall  only  say  that  pyrexia,  associated  with 
cough  and  pain  in  the  side  made  worse  by  forced  respiratory  move- 
ments, is  very  characteristic,  and  if  friction  sounds  are  heard  dis- 
tinguishable from  pericardial  ones  {vide  p.  126),  the  diagnosis  is 
complete.  I  have  already  (on  pp.  61  ^/  seq.)  drawn  attention  to 
other  more  obscure  cases  of  pain  in  the  side. 

Causes  of  Acute  Pleurisy. — These  may  be  divided  into  the  general 
and  the  local.  As  regards  general  causation,  experience  shows  that 
the  following  are  very  hable  to  an  attack : — 

(i)  Those  who  are  suffering,  or  are  hable  to  suffer,  from  rheu- 
matism, acute  or  subacute. 

(2)  Those  who  are  affected  with,  or  recently  convalescent  from, 
an  attack  of  an  acute  specific  fever,  including  influenza. 

(3)  The  \dctims  of  chronic  nephritis  of  any  form,  with  its 
associated  imperfect  elimination  of  waste  products,  and  its  anaemia. 

(4)  It  is  undeniable  that  a  fourth  group  must  be  inserted  of 
individuals  who  are  apparently  in  perfect  health,  but  get  an  attack 
of  pleurisy  as  the  result  of  what  is  ordinarily  termed  a  chill. 
Recent  observations  on  the  subsequent  history  of  such  individuals 
tend  to  reduce  the  number  of  genuine  idiopathic  cases  very 
materially,  as  a  large  proportion  of  them  have  proved  to  be  con- 
cealed tuberculosis. 

The  local  causes  are  : — 

(i)  Traumatism,  blows,  fractured  ribs,  crushes,  etc. 
(2)  Extension  of  inflammatory  processes — 

{a)  From  the  lung,  tubercle,  pneumonia,  bronchopneumonia, 

infarction,  absccss,  gangrene,  etc. 
{f)  From  the  pericardium  (rarely). 


I02  DIFFERENTIAL  DIAGNOSIS  chap. 

(c)  From  abdominal  viscera,  liver,  spleen,  etc.,  through  the 
diaphragm. 

(3)  Rupture  of  morbid  collections  into  the  pleura,  independ- 
ently of  the  inflammatory  process  reaching  it — phthisical  cavities, 
abscesses,  hydatids,  etc. 

Pleuritic  Effusion 

Symptoms. — Inasmuch  as  effusion  may  be,  and  frequently  is,  an 
associate  or  sequel  of  the  acute  affection,  however  arising,  the 
symptoms  of  acute  pleurisy  will  suggest  an  examination  for  fluid ; 
but,  on  the  other  hand,  effusion  frequently  takes  place  very  in- 
sidiously, without  obvious  precedent  disease  or  symptoms  of  suf- 
ficient severity  to  induce  the  subject  to  take  medical  advice,  and 
only  a  troublesome  shortness  of  breath  or  vague  chest  discomfort 
leads  him  to  submit  to  examination. 

Physical  Signs. — On  the  affected  side  we  find  : — 

On  inspection. — Some  loss  of  mobility  compared  with  the  sound 
side,  possibly  a  visible  displaced  heart's  apex  beat. 

On  palpation. — Tactile  vocal  fremitus,  absent  or  much  dimin- 
ished, possibly  heart's  apex  beat  felt  in  wrong  place. 

On  percussion. — Absolute  dulness  with  increased  resistance  to 
the  pleximeter  finger. 

On  auscultation. — Weak  or  absent  breath  sounds,  probably  of 
a  distant  tubular  character  owing  to  compression  of  alveoli 
and  finer  tubes  ;  a  peculiar  nasal  twang  is  given  to  the  voice 
sounds,  known  as  segophony.  Heart  sounds  heard  most 
clearly  in  a  displaced  position. 

Over  the  still  uncompressed  lung  the  sounds,  qua  effusion,  will 
b3  healthy,  but  the  breath  sounds  will  be  exaggerated  from  over- 
work. 

Causes  of  Pleuritic  Effusion  and  Hyd7'o-Thorax: — 

(i)  All  the  causes  of  acute  pleurisy  already  enumerated,  in  any 
of  which  eff"usion  may  be  a  predominant  feature,  or  may 
remain  after  the  acute  symptoms  have  subsided. 

(2)  Heart  disease,  with  its  obstructed  circulation. 

(3)  Malignant  disease  and  other  growths  {e.g.  hydatid)  within 

the  thorax. 

(4)  Tuberculosis  of  lung  or  pleura,  either  evident  or  concealed 

{vide  Causes  of  Acute  Pleurisy). 


IV  DISEASES  OF  THORACIC  ORGANS  103 

A  general  review  of  the  above  paragraphs  leads  to  an  inevitable 
conclusion  that  pleurisy  and  pleuritic  effusion  must  in  almost  all 
cases  be  reduced  to  the  rank  of  a  symptom,  possibly  it  may  some- 
times rise  to  the  dignity  of  an  independent  disease,  and  as  a 
symptom  it  may  occasionally  possess  the  importance  of  causing  a 
fatal  event ;  but,  on  the  whole,  its  features  and  pathology  must  be 
analysed  from  the  point  of  view  of  what  hes  behind,  and  not  as  the 
"  be  all  and  the  end  all "  of  a  diagnosis. 

The  Nature  of  the  Fluid. — Physical  signs  alone  enable  us  to  say 
that  fluid  is  present,  but  they  give  no  direct  information  as  to  its 
nature — unless,  indeed,  we  have  a  pointing  empyema,  which  is,  or 
should  be,  very  rarely  seen  nowadays.  Indirectly,  by  their  persist- 
ence, they  tell  us  that  the  fluid  is  not  being  absorbed,  but  this  may 
be,  and  generally  is,  due  to  circumstances  other  than  its  nature. 
Should  there  be  no  indications  of  these  circumstances,  such,  I 
mean,  as  obvious  morbus  cordis  or  pneumonia,  etc.,  we  are  then 
justified  in  saying  that  this  non-disappearance  is  probably  due  to 
the  fluid  not  being  simple  serum,  or  to  there  being  some  hidden 
and  persistent  cause  for  it  in  the  thorax,  e.g.  tubercle  or  carcinoma; 
cases  of  simple  idiopathic  pleuritic  effusion  resisting  absorption  for 
any  length  of  time  are  rare.  The  symptoms,  again,  strictly  speak- 
ing, are  not  of  much  use :  excessive  sweating,  anaemia,  weakness, 
and  hectic  temperature  are  certainly  suggestive  of  pus,  but  they  do 
not  exclude  tubercle  with  simple  serous  effusion,  nor,  indeed,  car- 
cinoma, which  I  have  found  on  the  post-mortem  table  after  such 
precedent  history.  There  is  but  one  method  of  ascertaining  with 
certainty  the  nature  of  the  fluid,  and  that  is  to  withdraw  a  little  by 
a  syringe  and  examine  it  with  the  naked  eye  and  (or)  microscopi- 
cally. 

The  following  considerations  will  show  that  even  now  our 
diagnosis  is  far  from  complete:  the  fluid  may  be  (i)  clear  watery, 
(2)  bloody  or  blood-stained,  (3)  milky  or  purulent,  (4)  stinking. 

{a)  If  it  be  clear,  it  is  either  hydatid-cyst  fluid — which  will  not 
coagulate  on  boiling  and  will  show  booklets — or  it  is  serum  ;  in  this 
latter  case  no  strong  deduction  can  be  made  from  the  information, 
for  every  single  cause  may  have  at  times  clear  effusion,  except 
ruptured  abscesses  and  gangrene,  both  of  which  have  probably 
given  other  and  clearer  proofs  of  their  presence.  It  is  in  clear 
effusions  that  inoculation  experiments  on  animals  are  so  useful  in 
clearing  up  a  doubtful  tubercular  diagnosis. 

{b)  If  it  be  turbid  or  definitely  purulent,  the  suggestion  is 
that  the  attack  is  strong  or  the  defence  weak,  which  is  not  very 


104  DIFFERENTIAL  DIAGNOSIS  chap. 

conclusive  information ;  empyema  is  common  in  children  and  in 
old  people  without  further  obvious  cause,  and  also  in  renal  cases 
and  drunkards,  but  I  have  met  with  it  as  the  product  of  carcinoma. 

(c)  Blood  or  blood-stained  serum  is  naturally  to  be  expected  in 
severe  traumatism  or  ruptured  aneurysm,  in  purpuric  or  scorbutic 
patients,  but  when  occurring  without  such  immediately  obvious 
antecedent,  it  certainly  leads  us  strongly  in  the  direction  of 
tubercle  or  carcinoma,  for  it  is  very  rare  in  simple  or  rheumatic 
cases. 

{d)  If  it  be  stinking,  we  have  conclusive  proof  that  the  microbes 
of  decomposition  have  gained  access  to  the  fluid,  but  how,  or  why, 
they  got  there,  we  must  learn  from  other  evidence  than  their  pres- 
ence. Some  cases  of  stinking  empyemata  unquestionably  do 
perfectly  well  after  simple  drainage,  proving  that  the  access  of  the 
microbes  was  not  gained  by  gross  lesions. 

It  will  thus  be  seen  that  the  nature  of  the  fluid  per  se  gives  but 
little  definite  or  decisive  indication  ^  as  to  the  real  meaning  of 
pleuritic  trouble;  serum  clear  or  blood-stained,  pus,  or  stinking 
fluid  may  each  apparently  occur  or  succeed  one  another  in  the 
same  case ;  the  point  is  of  great  importance  for  prognosis  and  treat- 
ment, but  we  must  look  elsewhere  for  clearer  indications  of  causa- 
tion. The  presence  of  acute  rheumatism,  or  the  history  of  its 
previous  occurrence,  an  account  of  severe  exposure  to  weather,  a 
present  or  recent  attack  of  an  acute  specific  fever,  of  pneumonia,  of 
bronchitis  or  bronchopneumonia,  advanced  tubercular  changes  in 
a  lung,  are  all  fairly  obvious  on  slight  inquiry  or  observation.  So, 
too,  heart  disease  or  chronic  nephritis  will  yield  unmistakable 
evidence  of  their  presence,  if  we  only  bear  them  in  mind  as  possible 
causes  and  look  for  them.  Any  of  these  would  be  admitted  as  a 
satisfactory  and  final  explanation  of  the  origin  of  the  trouble,  beyond 
the  natural  history  and  clinical  significance  of  which  we  need  not 
go  either  for  diagnosis  or  prognosis  ;  but  if  the  case  offers  no  such 
leading  indications,  we  have  now  to  decide  between  (i)  an  unusual 
case  of  apparently  idiopathic  pleural  effusion  ;  (2)  malignant  growth  ; 
(3)  tubercle  of  lung  or  pleura  concealed  by  the  fluid.  If  the  fluid 
has  persisted,  without  signs  of  absorption,  for  longer  than,  say,  two 
or  three  weeks  without  a  causative  diagnosis  becoming  reasonably 
certain,  we  should,  I  think,  empty  the  chest  as  completely  as  possible 
by  mechanical  means,  even  in  the  absence  of  urgent  symptoms  or 
other   reasons,   solely  for  the  purpose    of   establishing,   as  far  as 

^  Microscopic  or  bacteriological  examination  may  possibly  in  some  cases  g^ve 
absolutely  conclusive  proof  of  tubercular  or  malignant  disease. 


IV  DISEASES  OF  THORACIC  ORGANS  105 

possible,  a  fundamental  diagnosis  from  the  nature  of  the  fluid,  and 
from  the  changes  in  the  chest  produced  by  its  withdrawal.  The 
nature  of  the  fluid  we  have  already  seen  to  be  very  dubious  in  its 
indications,  though  so7tiethmg  may  be  guessed  from  it.  The 
changes  in  the  physical  signs  may  be  thus  analysed : — In  simple 
idiopathic  pleurisy  aspiration  will  certainly  cause  a  restoration  of 
some  degree  of  resonance  to  the  previously  dull  area,  and  the  lung 
will  soon  expand  with  a  return  of  distinct  breath  sounds,  probably 
intermingled  with  fine  and  coarse  crepitations,  owing  to  the  renewal 
of  the  circulation  through  previously  compressed  lung  tissue.  If 
the  case  is  a  tubercular  one,  it  is  again  probable  that  there  will  be 
some  restoration  of  more  natural  physical  signs  on  percussion  and 
auscultation,  but  it  will  not  be  so  complete  as  in  the  former  case, 
and  there  is  likely  to  be  some  evidence  of  patchy  consolidation, 
and  quite  possibly  friction  sounds  will  be  heard.  It  is,  too,  more 
probable  that  the  fluid  will  return,  though  in  either  case  this  may 
happen.  In  growth  of  more  gross  character  it  is  unlikely  that  the 
removal  of  the  fluid  will  alter  to  any  marked  degree  {vide  below) 
the  physical  signs  found  previously  ;  there  is  no  re-expansion  of  lung 
with  renewed  air  entry,  rapid  return  of  the  fluid  is  practically  certain 
to  take  place,  and  suspicion  becomes  greater  the  more  rapidly  this 
return  appears  without  pyrexial  phenomena  to  account  for  it. 

If  the  fluid  withdrawn  be  turbid  or  purulent^  this  is  in  itself 
strong,  but  not  absolute  proof  against  malignant  growth.  The 
most  important  point  to  bear  in  mind  with  pus  is  that  the  fibrinous 
coagula,  etc.,  are  apt  to  prevent  expansion  of  the  lung,  so  that 
greater  care  must  be  exercised  in  pronouncing  judgment  from  the 
absence  of  this  expansion.  It  is  also  very  rare — I  should  say  un- 
known— that  tubercle,  otherwise  indetedable^  should  cause  a  purulent 
effusion  as  the  first  sign  of  its  presence. 


INTRATHORACIC   TUMOURS 

Those  which  I  propose  to  discuss  here  are:  (i)  malignant 
growths ;  (2)  aneurysms.  Both  have  their  chief  features  in  common, 
viz.  irritation  and  pressure,  and  to  discuss  in  detail  every  variety 
of  each,  and  its  separate  diagnosis,  would  require  a  monograph 
to  itself.  I  only  propose  to  give  the  principles  on  which  such 
differentiation  must  proceed;  this  necessitates  as  a  foundation  a 
brief  sketch  of  the  nature  and  anatomical  relationships  of  the  two 
affections.  . 


io6  DIFFERENTIAL  DIAGNOSIS  chap. 

Malignant  Growths 

Are  in  nature — 
(i)   Primary.  {a)  Carcmoma. 

(b)  A  group   to  which  we  may  loosely  apply  the 
term  "  lymphosarcoma."  ^ 
(2)   Secondary.  Every  growth  or  form  of  it  which  can  cause  meta- 

static deposits,  or  invade  the  thorax  by  simple 
local  extension. 

Their  anatomical  relationships  may  be  thus  tabulated : — 
Starting  Point.  Progress. 


k;^  Almost  invariably  at  the  root  of 

c3  the    lung,    either   in    the   root 

.S  itself  or    glands    of    posterior 

Ph  or  upper  mediastinum. 

>^ 

c3  (a)  Anywhere  in  the  lung  tissue. 

fi  {b)  Creeping    into    the    medias- 

H  tina. 


Into  the  mediastina,  sur- 
rounding and  compressing  the 
structures  there,  and  forming 
a  large  solid  mass. 

Into  the  substance  of  the  lung, 
solidifying  it. 

Into  and  over  the  surface  of 
the  pleura   pericardium,  etc. 


I  have  grouped  these  together,  allowing  a  growth  to  proceed  in 
any  direction,  a  course  which  is  theoretically  true,  and  may  now 
and  again  be  taken  by  any  of  them,  but  clinical  experience  in  the 
post-mortem  room  shows  that : — 

1.  Primary  carcinomata  almost  always  spread  either  into  the 
lung  tissue  or  on  to  the  pleura,  or  both ;  they  practically  never 
invade  mediastinal  tissues  alone. 

2.  Primary  lymphosarcomata  practically  never  invade  either  lung 
or  pleura,  but  grow  steadily  in  the  mediastina,  compressing  the  lung ; 
the  pericardium  is  surrounded,  and  may  be  actually  invaded  on  its 
inner  surface,  causing  effusion  and  cardiac  difficulties. 

3.  Secondary  metastatic  deposits  from  a  distance  practically 
always  form  nodules  in  the  lung  substance,  solidifying  and  invading  it 
without  compression. 

4.  Secondary  extensions  from  mamma  or  oesophagus,  e.g.^  are 
the  especial  tumours  which  may  spread  in  any  direction. 

^  This  term  must  include  true  sarcomata,  and  also  the  ill-understood  enlarge- 
ments of  lymphatic  glands,  lymphadenoma,  Hodgkin's  disease,  etc. 


IV 


DISEASES  OF  THORACIC  ORGANS 


107 


Aneurysms 

May  be  classified  according  to  the  part  of  the  arch  from  which 
they  spring,  but  I  think  more  usefully  according  to  the  clinical  indi- 
cations, thus  : — 


Anatomically. 

Of  the  ascending  arch. 
Of  the  descending  arch. 
Of  the  descending  thoracic 
aorta. 

Of  the  transverse  arch. 


Clinically. 

The  aneurysms  of  physical  signs  especi- 
ally : 
__      {a)   Externally  bulging  tumour  with 
expansile  pulsation. 
{b)   Dulness  on  percussion. 
{c)  Audible  bruits. 
The  aneurysms  of  symptoms,  principally 
or   entirely  pressure    effects   on   neigh- 
bouring soft  tissues  {vide  p.  108). 


The  progress  of  any  aneurysm — upwards,  downwards,  forwards, 
or  backwards — is  governed  by  the  precise  point  in  the  circumference 
of  the  vessel  at  which  it  first  starts,  spreading  from  that  point  in 
all  directions  except  towards  the  parent  vessel. 

This  sketch  shows  that  the  two  conditions  cannot  be  separated 
by  anatomical  considerations  alone.  We  will  now  discuss  in  parallel 
columns  the  more  likely  explanation  of  certain  conditions. 


Aneurysm. 

Sex.  Many  times  commoner  in 

males. 

Occupation.  The    more    laborious    oc- 

cupation probably  ex- 
plains the  greater  fre- 
quency in  men. 

Age.  Usually  thirty-five  to  fifty. 


Alcohol.  Excess  undoubtedly  a  pre- 

disposing factor. 

Syphilis.  Is  undoubtedly  also  a  pre- 

disposing factor. 


Growth. 

No  predilection  for  either 
sex. 

Would  seem  to  have  no 
influence  in  inducing  a 
growth  primarily. 

Primary  commoner  under 
thirty-five,  but  second- 
ary at  any  age  corre- 
sponding to  the  primary 
growth. 

Without  influence. 

Has  no  influence  on  or- 
dinary growths  ;  and 
gummata,  large  enough 
to  cause  doubt,  are  ex- 
cessively rare. 


io8 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Complaint    of 
pain. 


Inspection    of 
patient. 


Auscultation. 


Aneurysm. 

Acute  pain  is  certainly 
suggestive  in  cases  of 
doubt,  but  no  conclusive 
evidence  from  this  point. 

Bulging  expansile  tumour 
pathognomonic  ;  but,  of 
course,  usually  no  evi- 
dence from  inspection 
in  cases  of  doubt.  CEde- 
ma  of  an  arm  occasion- 
ally seen,  but  of  one 
side  of  chest  alone  very 
rarely  if  ever. 


A  systolic  or  double  bruit, 
if  not  traceable  to  val- 
vular disease,  is  very 
suggestive  ;  even  if 
valvular  it  only  loses 
significance  if  patient 
be  young  and  has  suf- 
fered from  a  recognised 
cause  of  endocarditis. 
The  degenerative  pro- 
cesses of  age  tending 
as  much  to  aneurysm 
as  to  valve  destruction. 


Growth. 

If  present  it  is  more 
commonly  a  dull  op- 
pressive pain,  but  neur- 
algia may  occur. 

A  mass  of  enlarged  glands 
or  growth  above  clavicle 
also  pathognomonic  ;  a 
malignant  tumour  else- 
where is  very  suggestive 
in  doubtful  cases. 
OEdema  of  one  side  the 
chest  wall  very  sus- 
picious, and  if  without 
oedema  of  arm  almost 
conclusive. 

Bruits  have  no  connection 
with  tumour  as  such ; 
may  occasionally  occur 
if  heart  is  displaced, 
or  aorta  or  pulmonary 
artery  distorted,  but 
this  is  very  rare. 


Pressure  and  Invasion  Effects 


On  lungs.  Usually  causes    compres- 

sion only,  with  irritat- 
ing cough,  but  may 
start  an  acute  inflamma- 
tory attack  with  free 
haemoptysis. 


May  cause  compression 
only  by  growing  on  the 
pleura  {q.v.\  but  more 
frequently  assumes  the 
characters  of  an  insidi- 
ous consolidation  — 
often  multiple  in 
secondary  infection  — 
and  only  at  the  last 
when  breaking  down 
causes  aspiration-bron- 
chopneumonia. 


IV 


DISEASES  OF  THORACIC  ORGANS 


log 


On  trachea  and 
bronchi. 


On  pleura. 


On  veins. 


Aneurysm. 
Tracheal  tugging  ^  very 
characteristic  if  present ; 
may  cause  a  bronchitis, 
and  possibly  dyspnoea, 
but  vide  Nerves. 

Acute  pleurisy  a  much 
commoner  result  than 
quiet  effusion  ;  this  is 
because  an  aneurysm  is 
much  more  acutely  ir- 
ritating than  a  soHd 
neoplasm. 

Aneurysm,  until  too  large 
to  be  mistaken,  rarely 
presses  on  any  vein  ex- 
cept the  left  innominate, 
and  hence  the  oedema 
mentioned  under  In- 
spection not  usually 
aA-ailable  in  doubtful 
cases. 


Growth. 

Probably  causes  only  a 
slowly  progressive 
shortness  of  breath  from 
compression,  which  also 
leads  to  collapse  of  cor- 
responding area  of  lung. 

A  clear  or  blood-stained 
effusion,  very  common 
when  the  growth  reaches 
to  and  spreads  over  the 
pleura ;  it  is  probably 
more  due  to  venous 
blockage  than  a  real 
inflammatory  reaction. 

Tumour  of  size  or  extent 
to  be  still  doubtful  fre- 
quently catches  the  in- 
tercostal veins,  causing 
oedema  of  chest  wall  ; 
also  the  vena  azygos, 
causing  enlargement  of 
abdomino  -  thoracic 
veins;  the  left  innomin- 
ate, too,  or  even  a  vena 
cava,  may  be  caught 
early. 

Is  now  and  again  blocked 
by  a  growiih,  and  occa- 
sionally chylous  ascites 
has  appeared  from  this 
cause. 

Tumours  of  thorax  proper 
more  rarely  than  aneur- 
ysm cause  dysphagia ; 
should  they  do  so  its 
amount  is  likely  to  be 
unvar}'ing.  Carcinoma 
of  the  oesophagus  itself 
is  the  only  likely  one, 
.     .  and    then    the   gradual 

but  persistent  history  of 

^  A  peculiar  shock  s}Tichronous  with  the  pulsation  of  the  aneurysm,  felt  by  two 
fingers  laid  on  the  trachea  when  extended  to  its  utmost  by  throwing  back  the  head 
as  far  as  possible. 


Thoracic  duct. 


On  oesophagus. 


Practically  never  inter- 
fered with  by  a  doubtful 
aneurj'sm. 


Aneur^'sms  cause  dys- 
phagia, but  when  it 
arises  from  this  cause 
it  is  likely  to  var}'  in 
degree  on  occasions. 


no 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Aneurysm. 


On  nerves. 


On  bones. 


Effect    of    rest 
or  treatment. 


Duration         of 
symptoms. 


The  intermittent  beating 
of  an  aneurysm  appears 
to  be  more  .irritating 
than  a  growth  ;  the  re- 
current laryngeal  is  the 
nerve  par  excelle7ice 
of  aneurysmal  trouble, 
being  frequently  paral- 
ysed by  small  aneurysms 
of  the  arch. 

Destruction  of  bone  by 
aneurysm  is  very  pain- 
ful. 


The  symptoms  of  aneur- 
ysm show  spontaneous 
variations  in  intensity 
which  it  is  difficult  to 
account  for ;  they  are 
almost  invariably  im- 
proved, for  a  little  while 
at  all  events,  by  rest 
in  bed  and  other  treat- 
ment. 

From  clinical  histories  it 
would  appear  certain 
that  aneurysms  may 
last  for  a  long  time 
before  causing  a  fatal 
event,  hence  a  history 
of  symptoms  for  many 
months  or  a  year  or 
two  is  very  suggestive 
of  aneurysm  as  against 
growth,  though  perhaps 
more  against  either  of 
them. 


Growth, 
dysphagia  as  the  only 
symptom  is  the 
strongest  circumstantial 
evidence. 
A  growth  appears  to  cause 
but  little  active  irrita- 
tion to  nerves,  but  no 
general  rule  can  be  laid 
down.  Pain  is  certainly 
less  common  in  growth 
than  in  aneurysm. 


Intrathoracic  growths 
rarely  reach  and  erode 
bones,  but  one  growing 
from  the  bones  of  the 
thorax  would  cause  pain 
not  so  acute  as  that  of 
aneurysm. 

The  symptoms  of  growth 
rarely  show  even  the 
faintest  trace  of  im- 
provement under  rest 
and  treatment,  while 
judgment  is  suspended. 


All  cases  of  definite  tum- 
our end  fatally  within  a 
year,  hence  if  condition 
has  early  and  rapidly 
become  severe,  it  is  so 
far  in  favour  of  growth 
V.  aneurysm. 


IV  DISEASES  OF  THORACIC  ORGANS  iii 

These  points,  I  think,  include  the  bulk  of  the  evidence  we  shall 
have  to  weigh  in  a  given  case.  Few  only  of  them  are  decisive  or 
pathognomonic,  but  if  all  are  carefully  considered  I  think  we  shall 
usually  arrive  at  a  correct  conclusion. 


CHAPTER   \N— Continued 

DISEASES    OF   THORACIC    ORGANS 

Section  II. — Diseases  of  the  Heart  and  Pericardium 

Errors  of  judgment — if  not  of  actual  diagnosis — occur  more 
frequently  in  connection  with  heart  disease  than  with  the  troubles 
of  any  other  organ.  The  reason  is  somewhat  as  follows : — Before 
the  days  of  the  invention  and  perfection  of  the  stethoscope  heart 
disease  was  either  not  diagnosed  at  all,  or  it  was  guessed  at  by  pain 
and  morbid  sensations  in  the  thoracic  cardiac  area,  or  it  was 
recognised  by  evidences  of  circulatory  disturbance  and  the  character 
of  the  pulse.  These  indications,  without  the  assistance  afforded 
by  the  stethoscope,  were  apt  to  be  misleading.  Now  the  pendulum 
has  swung  too  far  the  other  way,  and,  armed  with  an  instrument  of 
precision,  we  are  all  too  apt  to  think  we  can  immediately  diagnose 
heart  disease  by  bruits  thus  brought  within  the  sphere  of  our 
objective  consciousness.  This  is  just  as  great  a  mistake  as  the 
former  condition  of  uncertainty.  That  we  can  thus  detect  a 
leaking  valve  or  a  stenosed  orifice  must  in  general  be  admitted — 
though  even  here  great  caution  is  necessary  in  interpreting  our 
aural  perceptions — but  this  is  often  enough  a  very  different  matter 
from  morbus  cordis.  Sir  Andrew  Clark  was,  I  believe,  the  first  to 
draw  public  attention  to  this.  He  compiled  a  very  long  list  of 
patients  in  whom  he  had  by  systematic  examination  detected  a 
cardiac  murmur,  but  whose  symptoms  and  complaints,  as  he 
showed,  had  no  derivation  whatever  from  a  diseased  heart.  His 
experience  we  all  of  us  can  now  confirm  from  out-patient  practice, 
but  it  seems  somehow  to  have  escaped  the  recognition  it  deserves 
at  the  hands  of  students  and  practitioners. 

It  may  then  well  be  asked  what  are  the  features  (symptoms 


CHAP.  IV  ISEASES  OF  THORACIC  ORGANS  113 

and  physical  signs  in  combination)  by  which  we  are  to  recognise 
genuine  heart  disease.  The  conditions  leading  to  a  suspicion  of 
heart  disease  are  divisible  into  two  main  groups:  (i)  local  in  the 
thorax  or  cardiac  area;  (2)  general,  expressed  in  or  by  distant 
organs  or  tissues ;  and  each  may  again  be  divided  somewhat 
indefinitely  into  symptoms  and  physical  signs  (p.  21).  We  will 
proceed  to  comment  briefly  on  each  division. 

Local  Thoracic  Symptoms  which  may  Indicate  the  Presence 

OF  Morbus  Cordis 

1.  Pain. — Pain  is  a  very  variable  feature  indeed.  It  may  be 
slight,  or  it  may  be  extraordinarily  severe  (typical  angina),  and 
almost  any  degree  of  it  may  be  associated  with  a  cardiac  condition 
of  absolutely  no  moment  at  all,  or  of  one  of  the  very  greatest 
danger  to  life.  The  only  general  statement  that  can  be  made 
about  it  is,  that  when  due  to  the  more  serious  troubles,  it  is  very 
liable  to  spread  from  its  original  position  and  extend  to  the  right, 
or  to  the  upper  chest  and  down  the  left  arm.  On  the  other 
hand,  when  owning  a  gastric  (its  most  common  source)  or  other 
than  cardiac  origin,  it  more  commonly  remains  fixed  to  the  cardiac 
area.  It  must  not  be  forgotten  that  the  pain  of  aneurysm,  of 
pericarditis,  and  of  left  pleurisy,  all  instances  of  serious  organic 
disease,  more  commonly  also  remain  as  a  stationar}^  pain.  In  any 
and  all  cases  we  must,  however,  make  a  careful  physical  examina- 
tion, for  by  the  results  of  this  our  judgment  of  the  pain  is,  after  all, 
mainly  influenced.  Pain  alone  must  not  be  accepted  as  evidence 
of  morbus  cordis,  though,  when  we  are  satisfied  that  the  pain  is 
genuinely  severe,  we  must  be  doubly  cautious  in  exonerating  the 
heart,  even  if  at  the  time  of  examination  there  remains  very  little 
or  no  evidence  of  abnormality. 

2.  Shortness  of  Breath  may  be  very  briefly  dismissed,  inasmuch 
as  it  may  be  due  either  to  pulmonary  or  cardiac  conditions,  and  it 
is  only  a  physical  examination  of  the  patient  that  can  determine 
which.  From  either  source  it  is  probably  associated  with  cough, 
and  made  worse  by  physical  exertion.  That  produced  by  cardiac 
disease  is  perhaps  more  definitely  relieved  by  raising  the  patient  to 
a  sitting  posture. 

3.  Cough. — Cough  perhaps  more  properly  belongs  to  the  general 
group  of  back  pressure  symptoms,  but  as  its  alternative  causation 
is  local,  it  may  be  mentioned  here.  If  due  to  cardiac  disease,  it 
will   be   either   dry,    ineffectual,    and   useless   cough,    and    is    then 

I 


114  DIFFERENTIAL  DIAGNOSIS  chap. 

suggestive  of  nervous  irritation,  perhaps  aneurysm,  or  it  will  be 
accompanied  by  some  expectoration,  but  this  will  be  simple  frothy 
mucus,  unless,  indeed,  there  be  hemorrhage,  when  the  mucus  will 
be  blood-stained  or  replaced  by  pure  blood  {vide  Haemoptysis,  p. 
54).  If  pus  or  other  organic  elements  be  present,  it  is  a  certain 
demonstration  that  the  cough  is  x\q>X.  purely  cardiac  in  origin. 

4.  Palpitatio?i. — This  simply  means  that  the  beat  of  the  heart 
has  become  perceptible  to  the  owner  of  the  organ.  It  is  extremely 
common  in  all  sorts  of  diseases  and  conditions  of  ill-health,  and 
especially  as  the  result  of  mere  introspection  and  morbid  self- 
consciousness.  Accordingly,  when  standing  alone,  without  objective 
signs  of  morbus  cordis,  it  is  almost  an  indication  against  that  con- 
dition as  its  real  source ;  but  when  associated  with  definite  abnor- 
malities of  mechanism  or  rhythm,  and  especially  if  then  constant, 
it  acquires  considerable  significance  in  the  case. 

We  thus  see  that  the  local  symptoms,  without  exception, 
require  a  careful  physical  examination  to  determine  their  value 
and  significance. 

Local  Thoracic  Physical  Signs  which  may  indicate  the 

Presence  of  Morbus  Cordis 

These  include  everything  which  can  be  seen  on  inspection,  felt 
by  palpation,  appreciated  by  percussion,  or  heard  on  auscultation. 
I  do  not  propose  to  discuss  these  in  any  detail,  but  shall  merely 
indicate  seriatim  what  aids  they  give  us  in  diagnosis. 

Inspection  is  very  frequently  quite  negative  in  its  results.  It 
may  show  a  heaving  impulse  of  great  hypertrophy,  or  the  pulsating 
tumour  of  an  aneurysm ;  the  apex  beat,  too,  may  be  visible  to  the 
eye,  and  its  position  is  of  great  importance  {vide  p.  102  for  its  use 
in  pulmonary  diseases).  A  rippling  wave  of  apex  beat  is  suggestive 
of  irregular  action,  or  possibly  of  pericardial  effusion,  and  recession 
near  it  in  systole  might  possibly  indicate  adherent  pericardium. 

Palpation  will  further  determine  the  apex  beat  and  be  convincing 
of  a  strong,  heaving  beat.  It  may  rouse  suspicion  of  irregular  heart 
action.  Stress  is  laid  by  some  on  a  thrill  which  may  possibly  thus 
be  felt.  It  certainly  is  corroboration  of  probable  mitral  stenosis 
when  a  doubtful  presystolic  bruit  is  heard,  but  is  frequently  felt 
with  faihng  heart  from  any  lesion,  and  also  may  be  appreciated 
often  in  thin  subjects  whose  hearts  are  above  suspicion,  so  that  I 
hold  it  very  cheaply  unless  other  and  more  certain  indications  of 
trouble  are  present. 


IV  DISEASES  OF  THORACIC  ORGANS  115 

Percussion  gives,  with  very  variable  results,  the  area  of  uncovered 
heart,  and  possibly  some  idea  of  the  gross  size  of  the  organ.  But 
it  is  so  subject  to  personal  variations  in  the  observer,  so  liable  to 
vary  in  health  in  different  individuals,  so  subject  to  fallacies  from 
the  position  of  the  lungs  in  health  and  disease,  that  it  is  wise  to 
reduce  it  to  a  very  low  level  of  diagnostic  utility.  The  preposterous 
claims  made  on  its  behalf  by  the  recent  upholders  of  the  Schott 
(and  other)  systems  of  treatment  have  reduced  its  value  still  lower, 
and  left  it  as  an  object  of  ridicule  to  thoughtful  men,  at  any  rate  as 
indicating  the  size  of  the  heart.  It  is,  however,  of  some  little  use 
in  helping  us  to  differentiate  between  a  pericardial  effusion  and  a 
hypertrophied  heart. 

Auscultatio7i. — By  auscultation  we  become  aware  of  several 
factors  in  the  heart  beat  which  are  of  very  unequal  significance 
individually,  but  collectively  constitute  our  most  important  know- 
ledge of  the  condition  of  the  heart.  They  may  be  enumerated  as 
(i)  the  ordinary  sounds  of  the  heart;  (2)  the  frequency  of  the 
beat;  (3)  the  regularity  of  cardiac  action  and  its  rhythm;  (4)  ab- 
normal sounds  or  bruits  added  to  or  replacing  the  natural  sounds. 

(i  and  2)  The  Ordiftary  Soimds  and  Fi'equeticy. — In  health  it  is 
well  known  that  the  first  sound  should  be  materially  longer  than  the 
second,  the  now  classical  lubb-dup  well  representing  the  difference. 
As  the  frequency  of  the  rate  increases  this  difference  must,  of 
course,  absolutely  diminish,  and  in  rates  of  over  (say)  150  is  practi- 
cally inappreciable ;  but  when  moderate  or  low  frequency  is  present, 
even  in  the  absence  of  other  abnormality,  a  comparative  shortening 
of  the  first  sound  is  a  serious  indication  of  some  change  in  the 
action.  It  may  indicate  mere  nervous  hypersensitiveness,  and 
then  the  rate  is  likely  to  be  high,  and  other  evidence  of  nervous 
instability  may  be  present  in  the  patient.  More  usually,  and 
especially  with  moderate  frequency  of  beat,  it  is  suggestive  of 
muscular  debility  or  hurry,  probably  the  result  of  degeneration,  or, 
at  least,  of  imperfect  nutrition,  and  makes  us  anxious  about  the 
supervention,  already  present  or  to  come,  of  a  pathological  yielding 
of  the  muscle  and  incapacity  to  continue  to  stand  the  strain  of 
present  pressure. 

(3)  Regularity. — So  long  as  the  action  of  the  heart  is  regular, 
and  its  rhythm  even,  so  long  may  we  make  a  very  substantial 
deduction  from  the  prognostic  gravity  of  almost  any  evidence  of 
defective  mechanism  or  circulatory  disturbance.  If  irregularity  be 
detected  especial  care  must  be  taken  to  ascertain  if  it  be  a  regular 
periodic  irregularity,  i.e.  an  occasional  dropped  beat  say  every  four, 


ii6  DIFFERENTIAL  DIAGNOSIS  chap. 

five,  or  six  beats,  or  if  it  be  a  totally  irregular  irregularity,  defying 
exact  description,  and  rhythm  totally  absent.  The  former  is  often 
a  harmless  condition,  and  may  even  be  beneficial  to  a  heart 
working  under  some  unusual  strain,  so  that  in  the  absence  of  other 
definite  indications  of  cardiac  failure  it  requires  only  to  be  noted 
for  future  reference,  but  is  not  to  be  treated  by  direct  efforts  at 
cardiac  medication.  The  latter,  a  tumultuous  irregularity  with 
many  beats  of  very  variable  strength,  is  a  very  grave  sign,  and 
indicates  the  urgent  need  of  prompt  interference  on  behalf  of  an 
overburdened  heart. 

(4)  Abnonnal  Sounds. — The  presence  of  an  endocardial  bruit 
(vide  p.  127,  to  differentiate  endo-  from  exocardial  bruits)  heard  in 
the  situation  and  conducted  in  the  direction  usually  laid  down  in 
text-books,  is  strong  evidence  of  leakage  through,  or  narrowing  of,  a 
valvular  orifice,  but  the  deductions  as  to  cardiac  disease  to  be  made 
from  this  evidence  are  of  very  unequal  importance  in  different  cases. 
In  rheumatic  fever  or  other  disease,  such  as  the  specific  fevers, 
known  to  be  a  possible  cause  of  endocarditis,  the  first  occurrence  of 
a  bruit  is  of  very  great  importance,  for  we  then  know  that  a  valve 
is  inflamed  and  softened,  and  we  get  a  strong  indication  for  giving 
such  valve  as  much  rest  as  possible.  Again,  in  a  case  of  smoulder- 
ing but  persistent  pyrexia,  the  source  of  which  is  not  obvious,  if  we 
hear  a  cardiac  bruit  which  was  not  present  before,  or  even  if  we 
were  previously  aware  of  its  presence,  but  it  seems  to  vary  in  char- 
acter at  times,  it  will  throw  strong  suspicion  on  that  valve  as  the 
seat  of  a  septic  or  simple  inflammation,  keeping  up  the  temperature 
and  threatening  very  serious  danger.  Thirdly,  when  some  of  the 
features  of  circulatory  disturbance  through  an  organ  or  district  are 
present,  a  bruit  is  certainly  suggestive  of  central  cardiac  failure  as  a 
probable  contributory  factor,  though  regularity  and  evenness  of  the 
cardiac  beat  are  much  more  important  features  than  the  bruit  itself. 
In  the  more  chronic  cases  of  valvular  trouble,  where  a  bruit  or  bruits 
have  been  known  to  exist  for  some  time,  neither  the  bruit  nor  the 
precise  form  of  trouble  indicated  by  it  is  of  great  importance,  for 
we  can  neither  treat  the  one  nor  place  any  great  rehance  on  the 
accuracy  of  the  other.  Speaking  then  in  general  terms,  bruits  are 
only  of  value  to  remind  us  (i)  when  they  first  appear,  they  are 
evidence  of  a  softened  valve  which  may  yield  on  pressure;  (2) 
when  old,  that  the  heart  is  working  with  imperfect  machinery, 
which  has  not  the  same  elasticity  for  emergencies  that  the  original 
sound  mechanism  possessed. 


IV  DISEASES  OF  THORACIC  ORGANS  117 


General  Symptoms  in  other  Organs  which  may  indicate 

Morbus  Cordis 

There  are  at  least  two  factors  in  the  production  of  those  symp- 
toms which  are  exhibited  by  other  organs  or  areas,  but  which  are 
usually  accepted  clinically  as  indicative  of  cardiac  disease.  They 
are  :  (i)  the  work  of  the  heart  and  aorta;  (2)  the  work  of  the  smaller 
arteries,  arterioles,  and  capillaries  interacting  with  the  lymphatic 
circulation  through  the  part  in  question. 

The  heart  is  a  driving  and  suction  pump,  introduced  into  the 
closed  system  of  tubes,  by  means  of  which  the  blood  is  kept  circul- 
ating, and  as  such  its  nervous,  valvular,  and  muscular  mechanisms 
are  perfectly  adapted  for  fulfilling  its  part  in  the  total  result,  viz. 
that  of  keeping  up  a  sufficient  head  of  pressure  in  the  aorta  and 
pulmonary  artery,  and  relieving  by  suction  the  largest  venous  trunks 
of  their  low  pressure  contents.  The  aorta  in  turn,  distended  and 
stretched  by  this  charge  of  blood  at  high  pressure,  should,  by  its 
elastic  recoil,  be  able  to  transmit  the  charge  and  pressure  in  gradu- 
ally diminishing  degrees  to  the  arteries  smaller  than  itself.  The 
greater  or  less  frequency  of  the  heart  beat,  and  its  greater  or  less 
force,  are  regulated  by  the  central  nervous  system  only  according 
to  the  very  general  needs  and  conditions  of  the  body  at  large  as  a 
whole.  It  is  to  the  second  of  the  above  factors,  viz.  arteriolar, 
capillary,  and  lymphatic  action  that  we  have  to  mainly  look  for  the 
regulation  of  the  blood  supply  for  the  local  needs  of  individual 
organs  for  particular  purposes,  and  also  for  an  explanation  of  the 
finer  problems  of  local  nutrition  and  function.  That  this  is  in 
many  cases  the  most  important  factor  is  strongly  suggested,  if  not 
proved,  by  cases  where  death  has  taken  place  with  the  patient  in  a 
water-logged  condition,  and  yet  post-mortem  examination  has  shown 
the  heart  itself  healthy  enough,  in  both  muscle  and  valve,  to  keep 
up  its  part  of  the  circulation  for  a  long  time  if  local  conditions  had 
allowed  or  assisted  their  share  of  work  to  be  done.  It  must  be 
admitted  that  improvement  in  the  heart's  action  is  frequently  fol- 
lowed by  the  happiest  possible  results  in  distant  parts,  so  that  it  is 
impossible  in  clinical  medicine  to  separate  and  identify  the  exact 
shares  of  each  factor ;  none  the  less  the  effect  of  digitalis  or  supra- 
renal extract  on  the  one  hand,  and  of  iodide  of  potassium,  nitro- 
glycerine, or  erythrol  tetranitrate  on  the  other,  compel  us  to  bear 
m  mind  the  peripheral  as  well  as  the  central  circulatory  factors. 
Whichever  of  the  two  is  at  fault,  or  if  both  be  so,  the  ultimate  local 


ii8  DIFFERENTIAL  DIAGNOSIS  chap. 

result  from  a  clinical  point  of  view  is  much  the  same.  It  is  to  be 
remembered,  too,  that  the  precise  nature  of  any  valvular  defect  in- 
fluences only  the  time  when  circulatory  disturbances  appear,  and 
then  the  order  or  sequence  in  which  they  occur ;  it  has  no  general 
influence  on  the  result,  provided  that  cardiac  muscular  failure 
actually  supervenes.  The  result  itself  is,  in  the  first  place,  a  dimin- 
ished arterial  supply  of  fresh  blood,  together  with  an  imperfect  or 
inadequate  removal  of  the  impure  venous  blood,  and  renewal  of 
nutrient  lymphatic  plasma.  This  circulatory  disturbance  leads  in  its 
turn  to  interference  with  the  work  of  organs  with  an  active  function, 
and  to  oedema  or  effusion  in  areas  of  less  functional  activity.  In 
the  second  place,  this  sluggish  capillary  venous  and  lymphatic 
circulation,  with  excessive  pressure  on  the  venous  side,  leads  to  an 
alteration  in  the  quantity  and  quality  of  the  natural  exchanges 
between  blood  capillaries  and  lymphatic  channels,  and,  in  fact,  alters 
in  toto  the  vital  conditions  existing  in  the  part  in  question.  Thus 
we  find  not  unfrequently  that  a  venule  actually  ruptures  with  gross 
effusion  of  blood,  or  individual  red  cells  escape  and  die  in  an  extra 
vascular  situation,  or  finally  the  blood  may  coagulate  in  the  venules 
from  unnatural  composition,  leading  to  a  condition  known  as  in- 
farction. Ultimately,  but  gradually,  fibrin  coagulates  from  the  altered 
lymph,  and  causes  a  thickening  of  the  capillaries  and  fibrosis  of  the 
tissues,  and  the  pigment  from  the  dead  red  corpuscles  stains  the 
tissues.  Again,  we  have  embolism  occurring,  not  as  the  result  of 
general  circulatory  conditions,  but  owning  a  particular  cause  in 
either  loosened  vegetations  from  endocarditis,  or  clotting  of  blood 
in  the  irregularities  of  a  cardiac  chamber,  with  subsequent  loosening 
of  the  clot  into  the  circulation.  The  symptoms  occurring  in  these 
various  ways  throughout  the  body  may  be  tabulated  briefly  as 
follows : — 

o         -  r  u     1  Post-mortem  appearances 

Organs.  Symptoms  of  back  ^^^^^  ^^  .  ^f  ,^rt » 

P'^^^^^'^^-  organs. 

Lungs.                                  Shortness    of    breath,  Drier  than  usual  and 

cough  dry  or  with  tougher,  more  re- 
simple  frothy  mu-  sistant  to  attempted 
cous  expectoration,  laceration  by  finger; 
moist  sounds  at  one  probably  discoloured 
or  both  bases.  In-  from  old  blood  pig- 
farction  or  embolus  ment  (brown  indur- 
leads  to  bloody  ation)  ;  round  or 
sputum,   and   prob-  wedge-shaped    area 


IV 


DISEASES  OF  THORACIC  ORGANS 


119 


Organs. 


Pleura. 


Liver. 


Spleen. 


Stomach 
tines. 


Kidneys. 


and     intes- 


Brain. 


Limbs. 


Symptoms  of  back 
pressure. 

ably  pleuritic  pain 
and  rub  with  physi- 
cal signs  of  con- 
solidation :  this  used 
to  be  termed  pul- 
monary apoplexy. 

Pleural  effusion  com- 
mon, with  appropri- 
ate physical  signs. 

Tender  or  even  pain- 
ful, and  somewhat 
enlarged  to  the  ex- 
amining hand. 

Possibly  enlarged,  may 
be  vague  pain  in 
region. 


Dyspepsia,  flatulence, 
and  constipation  fre- 
quent ;  severe  vom- 
iting often  seen. 

D  iminution  in  secretion 
even  to  almost  com- 
plete suppression  ; 
slight  albuminuria 
very  common. 

Headaches,  confusion 
of  mind,  sleepless- 
ness, noises  in  head, 
flashes  of  light, 
etc.  ;  apoplexy  of 
some  form  common 
enough. 

Pitting  oedema,  especi- 
ally in  the  legs. 
Emboli  of  arteries. 


Post-mortem  appearances 

known  as  "  heart" 

organs. 

of  consolidation  = 
infarction  or  em- 
bolus. 


Excess  of  fluid  in  the 
cavity. 

Congestion  of  intra- 
lobular veins,  well- 
known  nutmeg  liver. 

Very  firm,  may  be 
small  or  large,  and 
possibly  wedge- 
shaped  areas  of  em- 
bolism. 

Veins  very  prominent, 
and  mucous  mem- 
brane dark  and 
congested ;  possibly 
slight  ulceration. 

Kidneys  very  firm  on 
section;  cortex 
equally  congested 
with  the  medulla. 

(?)  serous  apoplexy ; 
brain  often  seems 
more  juicy  than 
normal.  Embolus 
a  well-known  cause 
of  softening. 


It  is  particularly  important  to  remember  that  any  organ  whose 
vitality  and  circulation  are  thus  interfered  with  is  in  a  condition  in 
which  very  slight  irritation  will  cause  an  acute  outburst  of  inflam- 


I20  DIFFERENTIAL  DIAGNOSIS  chap. 

mation.  Bronchitis  and  acute  nephritis  are  thus  two  very  common 
compUcations,  and  it  is  often  a  matter  of  some  importance,  but 
great  difficulty,  to  determine  whether  the  bronchi  and  kidneys  are 
simply  venously  congested  or  actively  inflamed.  I  am  accustomed 
to  rely  upon  a  muco-purulent  v.  mucus  sputum,  and  the  presence 
or  absence  of  dry  musical  rhonchi  in  the  one  case,  of  epithelial 
casts  with  facial  oedema  in  the  other  case,  as  the  most  reliable 
points  of  distinction. 

Such,  then,  are  the  means  we  have  for  determining  the  presence 
of  real  heart  disease,  and,  like  similar  evidence  on  any  other  point, 
each  factor  has  to  be  weighed  first  individually^  and  then  in  addi- 
tion to,  or  subtraction  from,  all  other  factors,  and  a  balance  struck 
with  every  possible  care. 

The  matter  will  be  referred  to  again  in  dealing  with  nervous  v. 
valvular  and  muscular  heart  troubles  {vide  pp.  137  ^^  seq.\ 

We  may  now  consider  the  pathology  of,  and  the  meaning  of,  the 
terms — 

HYPERTROPHY  AND  DILATATION,  COMPENSATION 

AND  FAILURE 

Hypertrophy 

It  is  a  provision  of  nature,  distinctly  tending  to  the  preservation 
of  individuals,  that  healthy  muscle  should  increase  in  volume  and 
strength  (growth  or  hypertrophy)  in  proportion  to  the  work  it  is 
called  upon  to  do,  provided  that  this  at  first  lies  within  the  original 
capabilities  of  the  muscle.  The  heart  is  no  exception  to  this  rule, 
and  when  its  circulatory  work  from  any  cause  (nervous,  valvular,  or 
connected  with  increase  in  general  blood  pressure  from  kidney 
disease)  is  persistently  maintained  above  its  original  average,  the 
cardiac  muscle  hypertrophies  or  grows  to  meet  the  demand,  pro- 
vided that  the  nutritional  powers  in  general  of  the  individual  are 
fairly  good.  Temporary  increase  in  work  is  inherently  provided  for 
by  a  reserve  excess  of  potential  energy  over  that  habitually  put  forth. 

It  is  easy  to  understand  in  general  terms  that  if  the  mechanism 
of  the  heart  was  originally  adapted  to  work  with  the  greatest  pos- 
sible efficiency  (and  we  have  every  reason  for  such  belief),  any 
alteration  in  that  mechanism  must  involve  increased  expenditure  of 
energy  to  produce  the  same  result,  i.e.  increased  work.  We  have 
just  seen  in  the  previous  paragraphs  that  the  symptoms  of  disease 
of  the  heart  as  expressed  by  organs  other  than  itself  are  largely  (the 


IV  DISEASES  OF  THORACIC  ORGANS  121 

vasomotor  factor  must  not  be  forgotten)  indicative  of  failure  of  the 
heart  to  do  this  increased  work.  All  the  means  which  unaided 
nature  can  take  to  bring  about  a  fresh  balance  of  work  and  power 
are  collectively  spoken  of  as  compensation,  and  hence  compen- 
sation clinically  means  regained  (if  lost)  or  maintained  capabi- 
lity of  the  heart  to  do  its  work  under  unusual  or  altered  conditions. 
For  a  per7nanency  this  is,  to  all  intents  and  purposes,  hypertrophy. 
Tenipora?y  natural  compensation  was  mentioned  above  as  a  mere 
use  of  potential  inherent  energy,  and  artificially  we  can  produce 
temporary  compensation  by  diminishing  the  work,  as  by  rest  in  bed 
or  vasodilator  drugs. 

Following  this  argumient,  it  is  obvious  that  hypertrophy  has 
only  one  cause — increased  work.  It  is  actually  the  result  of,  and 
can  only  be  equal  to,  this  increase,  and  then  it  must  logically  be 
deduced  that  the  symptoms  of  hypertrophy  are — the  absence  of 
symptoms  of  heart  disease.  Disappearance  of  these  symptoms 
when  present  means  the  development  of  compensation,  and  if  per- 
manent this  means  hypertrophy. 

It  must  be  admitted  that  there  are  circumstances  under  which 
hypertrophy  may  be  indirectly  the  possible  cause  of  some  trouble. 
If,  for  instance  (as  in  athletes,  soldiers,  etc.),  great  physical  exer- 
tion has  called  forth  considerable  hypertrophy,  then,  when  the  work 
is  permanently  given  up,  the  heart  probably  will  not  diminish  in 
bulk  in  proportion  to  its  diminished  duties,  and  its  beat  may 
become  inconveniently  apparent  to  its  owner.  It  is  possible  that 
its  powerful  action  may  rupture  an  artery  that  is  healthy.  Certainly 
it  is  a  source  of  danger  to  vessels  that  are  not  healthy,  and  arterial 
disease  and  degeneration  are  unfortunately  only  too  frequent 
results  of  the  same  conditions  as  those  which  require  hypertrophy 
of  the  heart.  In  this  sense  hypertrophy  of  heart  may  be  described 
as  a  predisposing  factor  in  cerebral  haemorrhage,  but  in  all  other 
senses  hypertrophy  is  a  purely  defensive  expression  of  nature — a 
physiological  and  not  a  pathological  phenomenon. 

Dilatation 

We  may  say  at  once  that  this  term  is  used  in  two  distinct,  and 
in  some  respects  almost  opposed,  senses.  The  first  is  a  mere 
mechanical  increase  in  the  capacity  of  a  chamber.  The  second 
sense  takes  note  of  only  one  of  the  possible  consequences  of  this 
increased  capacity,  and  is  the  equivalent  of  cardiac  failure. 

As  regards  the  first  meaning,  theoretical  considerations  would 


122  DIFFERENTIAL  DIAGNOSIS  chap. 

show  that  it  is  an  inevitable  and  universal  result  of  valvular  in- 
capacity, though  I  am  strongly  inclined  to  doubt  if  it  is  possible  to 
prove  the  position  by  post-mortem  evidence  (the  conditions  of  rigor 
mortis,  and  the  effects  of  pressure  upon  dead  muscle,  do  not  suffi- 
ciently closely  correspond  to  the  reaction  of  living  muscle  to  its  environ- 
ment) ;  anyhow,  the  occurrence  of  dilatation  in  this  sense  has  no 
possible  importance  from  a  clinical  point  of  view,  provided  that  the 
energy  of  contraction  and  the  strength  of  the  chamber  i?z  question  are  in- 
creased in  proportion}  the  object  of  the  muscular  walls  being  merely 
to  empty  the  cavity  with  sufficient  force. 

The  second  sense  in  which  dilatation  is  used  is  exactly  repre- 
sented by  the  absence  of  this  requisite  energy  of  contraction  and 
absolute  strength,  and  it  is  precisely  this  that  4S  the  cause  of  the 
symptoms  of  morbus  cordis.  This  is  heart  failure,  or  absence  of 
compensation.  It  is  under  these  circumstances  that  a  previously 
hypertrophied  heart  becomes  a  nuisance  to  its  possessor  by  its 
tumultuous  efforts  to  cope  with  the  work  to  which  it  is  no  longer 
equal.  It  is  when  this  failure  or  stretching  becomes  excessive  that 
relative  incompetency  of  healthy  valves  supervenes,  for  they  are  no 
longer  capable  of  closing  an  orifice  which  has  become  too  large. 


DIAGNOSIS  OF  HYPERTROPHY  AND  DILATATION 

As  the  presence  of  one  or  other  or  both  of  these  conditions 
is,  one  might  say,  the  very  essence  of  99  per  cent  of  cardiac  patho- 
logy, the  recognition  of  them  becomes  at  once  the  cardinal  point  in 
diagnosis. 

Of  dilatation  in  its  first  or  simple  sense  there  is  no  positive  objec- 
tive sign  at  all,  and  its  presence  is  a  matter  of  no  moment  if  the 
requisite  muscle  strength  is  present  to  compensate  it.  Its  pre- 
sence is  assumed  in  all  cases  in  which  a  large  heart  is  due  to  val- 
vular alterations ;  in  other  cases  {e.g.  that  due  to  renal  disease — 
so-called  concentric  hypertrophy)  it  is  probably  absent. 

In  all  cases,  and  in  any  sense  of  the  word,  the  condition  of 
dilatation,  as  well  as  that  of  hypertrophy,  demands  for  its  presence 
a  heart  larger  than  usual  {i.e.  for  an  average  environment  of  age, 
work,  etc.),  and  therefore  we  require  as  the  first  element  in  diag- 
nosis the  signs  by  which  we  may  recognise  an  enlargement  of  the 
heart. 

^  It  must  be  remembered  that  this  proportion  is  a  large  one,  viz;  the  cube  of  the 
figure  representing  increase  in  diameter. 


IV 


DISEASES  OF  THORACIC  ORGANS 


123 


The  ordinary  physical  signs    by   which   this   is    done,    and    the 
principal  fallacies,  are  the  following : — 


Insf'ectio?!. — The  apex  beat  may 
be  seen  displaced  outwards,  or 
downwards  and  outwards.  A 
lifting  of  the  whole  cardiac  area 
of  the  chest  may  be  seen  at  each 
beat,  or  possibly  a  persistent 
bulging. 

Palpatio )i. — The  displacement  of 
the  apex  beat  may  be  felt,  as 
well  as  the  heaving.  If  a  thrill 
is  felt  it  is  also  a  suspicious  sign, 
and  must  be  noted. 

Percussion. — There  will  be  in- 
creased area  of  cardiac  dulness, 
both  absolute  and  relative. 


Fallacies. 
These  physical  signs  found  by  in- 
spection,  palpation,  and  percus- 
sion may  be  : — 

1.  Obscured — as  by  abundant  fat 
or  muscle  over  the  chest,  by 
emphysematous  lung,  by  peri- 
cardial effusion. 

2.  Rendered  unduly  prominent  by 
wasting  of  fat  or  muscle,  by  re- 
traction of  lung,  by  deformity 
(pigeon  breast.  Pottos  curvature, 
etc.)  of  the  chest. 

3.  Their  interpretation  may  be  a 
mistaken  one,  in  that  tumours 
or  effusions,  etc.,  may  displace 
the  heart,  its  apex  beat,  and 
cause  transmitted  pulsation  and 
bulging. 

Auscultation  is  interfered  with  by 
much  the  same  circumstances 
as  the  other  methods.  But,  in 
addition,  we  have  to  differen- 
tiate heart  sounds  from  those 
of  pericardial,  pulmonary,  and 
pleural  origin  {vide  p.  127). 


Auscultation  will  confirm  other  in- 
dications, or  decide  by  itself  the 
position  of  the  apex  beat.  If 
bruits  of  organic  origin  {vide 
p.  129)  are  present,  and  known 
to  have  been  so  for  some  time, 
the  presence  of  a  heart  larger 
than  usual  is  at  once  certain. 
If  no  bruits  are  present  the 
character  of  the  two  sounds 
must  be  noted.  They  are 
chiefly  of  use  to  separate  pure 
hypertrophy  from  dilatation  or 
failure. 

If  by  these  means  we  have  ascertained  that  a  large  heart  is 
present,  the  only  other  problem  requiring  solution  is  this :  Is  it 
capable  of  continuing  to  do  its  work  or  not  ? 

In  by  far  the  greater  number  of  cases  the  answer  is  obvious  at 
a  glance.  The  symptoms  of  failure  are  too  obtrusive,  or,  on  the 
other  hand,  the  absence  of  such  symptoms  is  quite  complete ;  but, 
excluding  the  extremes,  we  meet  with  many  cases  in  which  the 
most  careful  attention  to  every  feature  may  still  leave  us  in  doubt. 


124  DIFFERENTIAL  DIAGNOSIS  chap. 

Such,  for  example,  as  a  young  woman,  possibly  pregnant  too,  com- 
plaining of  some  puffiness  of  the  ankles  at  night,  and  we  find  her 
anaemic  and  the  possessor  of  a  mitral  bruit  (the  relative  shares  of 
anaemia  and  heart  and  pregnancy  require  much  consideration) ;  or, 
again,  an  elderly  patient  with  renal  trouble  complaining  of  short- 
ness of  breath — Is  it  cardiac  or  renal,  is  the  heart  begt?i?itng  to  fail  ? 
By  attention  to  the  following  considerations  we  shall  not  com- 
plete our  diagnosis,  but  we  shall  at  least  get  a  strong  body  of  evi- 
dence condemning  or  acquitting  the  heart  of  being  particeps 
criinmis : — 

Inspection  \  Will  none  of  them  help  us  much.  They  will  reveal  fre- 
Palpation  \  quency  and  irregularity,  but  these  are  much  better  deter- 
Percussion  j       mined  by  auscultation. 

Auscultatio7i  will  give  us  accurate  information  on — 

1.  Frequency  of  Pulse. — It  is  not  the  absolute  frequency  that  is 
of  so  much  importance.  A  weak  and  failing  heart  may  be  either 
slow  or  frequent,  fatty  hearts  are  often  slow,  and  sound  hearts 
often  beat  over  90  per  minute.  What  is  of  importance  is  the 
rapidity  with  which  the  heart  settles  down  after  a  temporary  in- 
creased frequency.  The  patient  should  be  made  to  exert  himself 
smartly  for  a  few  moments,  and  then  the  number  of  beats  in  the 
next  four  or  five  quarters  of  a  minute  should  be  registered  and  com- 
pared. If  the  muscle  is  good  the  numbers  will  rapidly  diminish 
with  each  succeeding  fifteen  seconds,  till  the  rate  is  regained  which 
was  previously  present.  If  the  increased  frequency  continues  it  is 
a  suspicious  circumstance  against  the  muscle. 

2.  Irregularity  of  Beat  in  a  large  heart  is  very  suspicious,  and  if 
due  to  muscle  failure  will,  I  believe,  be  invariably  associated  with 
grave  features  which  cannot  be  misunderstood.  It  is  only  in  hearts 
of  average  size  that  its  indication  is  doubtful,  and  then,  I  think,  it 
makes  one  suspect  the  nerves  rather  than  the  muscle  in  any  case 
where  there  is  room  for  genuine  doubt  as  to  the  presence  of  heart 
failure  {vide  pp.  117^/  seq^. 

3.  The  Character  of  the  Sounds. — If  the  natural  heart  sounds  be 
replaced  entirely  by  bruits  we  lose  the  assistance  they  usually  afford 
us,  and  we  must  rely  all  the  more  upon  the  regularity  of  the  beat 
and  other  indications.  If  they  be  not  thus  entirely  lost,  but  are 
audible  with  greater  or  less  distinctness,  it  must  be  borne  in  mind 
that,  with  an  increase  in  bulk  of  healthy  muscle,  there  is  an  increase 
in  the  contrast  between  the  first  and  second  sounds.  The  first 
sound  is  lengthened,  and  the  second  sound  made  sharper.     As  the 


IV  DISEASES  OF  THORACIC  ORGANS  125 

muscle  becomes  unhealthy  or  fails  in  power  this  contrast  becomes 
less,  and  we  may  lay  down  the  rule — "  The  more  the  first  sound 
approximates  in  character  to  the  second,  the  more  do  we  fear  that 
hypertrophy  is  being  overtaken  by  dilatation  or  weakness."  If  the 
first  sound  is  very  weak,  almost  inaudible,  this  is,  excluding  fallacies 
of  emphysematous  lung,  etc.,  a  sure  sign  of  failing  muscle. 

General  Sy77ipto7ns. — We  can  only  repeat  again  that  back  pressure 
effects,  if  definitely  present,  are  essentially  signs  of  failure.  Their 
absence  or  amelioration  is  provided  for  by  hypertrophy,  and  hence 
they  conclusively  prove  by  their  presence  that  the  muscle  is  feehng 
the  strain. 

We  may  now,  with  these  views  of  hypertrophy  and  dilatation, 
briefly  examine  the  elements  of  the  problem,  "  How  is  the  heart 
itself  affected  by  various  valvular  affections  ?  " 

^  ,  t  h    /  Competent. 

\  Incompetent.  [  Relative,  from  too  wide  an  orifice. 
<  Absolute,  from  intrinsic  disease 
(       (thickened,  puckered,  etc.). 

Orifices  must  be  i.   Correctly  adapted  for  their  valves. 

2.  Narrowed  (by  adhesions). 

3.  Too  large  (by  dilatation  of  chamber). 

A  moment's  consideration  of  any  single  valve  trouble  will  at 
once  show  that  any  pathological  change  in  the  structure  or  orifice 
leading  to  the  leakage  or  stenosis  must  throw  extra  work  on  to  that 
chamber  which  (reckoning  from  the  direction  of  the  blood  stream) 
immediately  precedes  the  lesion,  and  hence  we  might  infer  that 
hypertrophy  should  be  the  immediate  result.  But  as  the  extra 
work  is  thrown  on  to  the  chamber  at  very  different  periods  in  its 
cycle  of  work  and  rest,  the  results  are  not  quite  the  same  in  the  two 
cases.  In  pure  stenosis  the  extra  strain  comes  during  systole  when 
the  muscle  is  expecting  to  work,  and  here  we  can  easily  understand 
that  almost  pure  hypertrophy  results.  In  simple  incompetency  of 
a  valve,  however  produced,  the  strain  comes  on  the  precedent 
chamber  at  a  moment  when  the  muscle  is  relaxing  or  resting,  and 
hence,  being  caught  unawares,  so  to  speak,  it  is  likely  to  yield 
somewhat,  and  an  increase  in  the  volume  of  the  cavity  is  likely  to 
ensue,  or  dilatation  in  its  first  sense,  and,  unless  compensating 
energy  or  strength  appears,  dilatation  in  the  second  sense  will  soon 
appear.  This  precedent  chamber  (in  incompetency  at  any  rate) 
contains  a  larger  quantity  of  blood  than  usual,  which  will,  in  systole, 
be  forced  into  the  succedent  chamber  at  a  time  when  it  is  relaxing 


126  DIFFERENTIAL  DIAGNOSIS  chap. 

or  resting,  and  hence  in  this  chamber,  too,  there  must  occur  some 
degree  of  dilatation  to  be  again  compensated  by  hypertrophy. 
When  two  or  more  valves  are  affected,  and  possibly  in  different 
ways,  the  problem  becomes  more  difficult  to  follow,  but  the  above 
principles  will  help  us,  provided  we  have  the  data  as  to  time  and 
amount  of  the  several  affections.  Such  data  are,  however,  practi- 
cally never  offered  to  us,  and  we  have  to  be  content  with  accepting 
the  general  clinical  result  that  in  all  cases  of  chronic  valvular  disease 
of  the  heart  the  organ  becomes  larger  in  its  dimensions  as  ascer- 
tained by  physical  examination.  This  enlargement  is  nature's  effort 
at  compensation,  and  when  the  hypertrophy  reaches  its  limits,  or 
the  muscle  from  any  cause  becomes  badly  nourished,  cardiac  failure 
and  serious  symptoms  will  supervene,  whatever  be  the  actual  capa- 
city of  the  chambers. 


CARDIAC  BRUITS,  AND  SOUNDS  THAT  MAY  BE 
MISTAKEN  FOR  THEM 

If,  on  auscultation  of  a  chest,  an  abnormal  sound  be  heard  in 
the  cardiac  or  aortic  region,  the  first  point  to  determine  is,  whether 
its  origin  lies  in  the  cardiac  or  pulmonary  organs.  This,  as  a  rule, 
is  not  difficult  to  decide.  Pleuropericardial  friction  sounds  re- 
sembling a  pericardial  rub,  and  compression  of  a  small  portion  of 
lung  tissue  by  the  heart's  movements,  with  a  noise  resembling  a 
short  systolic  bruit,  are  the  chief  difficulties. 

In  the  first  place,  they  will  either  of  them  only  be  heard  locally 
where  they  arise,  somewhere  along  the  margin  of  the  heart.  This 
and  their  rough  character  will  alone  be  sufficient  to  separate  them 
from  endocardial  bruits,  which  are  heard  over  the  bulk  of  the  heart, 
and  always  conducted  at  least  a  little  way  from  the  point  of  maxi- 
mum intensity.  Then  if  by  making  the  patient  hold  his  breath  for 
a  few  seconds  the  sound  entirely  ceases,  we  know  at  any  rate  that 
the  inside  of  the  pericardium  is  free  from  acute  inflammation,  and 
this  is  the  most  important  clinical  point,  for  an  acute  pleurisy  here 
is  only  of  additional  importance  from  the  liability  to  spread  to  the 
inner  surface  of  the  pericardium.  If  the  sound  does  not  entirely 
disappear  on  holding  the  breath,  the  heart  movements  must  take 
some  share  in  its  production.  Probably  the  pericardium  is  adherent 
to  the  heart  on  the  one  hand,  and  the  pleura  on  the  other.  The 
position  in  which  such  sound  is  heard,  on  the  boundary  or  just  out- 
side the  limits  of  the  heart,  and  a  history  of  previous  pericarditis  or 


IV 


DISEASES  OF  THORACIC  ORGANS 


127 


pleurisy,  will  help  us  in  deciding  pleura  v.  pericardium,  though 
frequently  it  is  quite  impossible  to  decide  the  point.  Nor  is  the 
decision  of  very  great  importance  practically,  for  either  solution 
suggests  adhesions  which  may  in  the  long  run  interfere  with  the 
cardiac  muscle,  and  are  consequently  to  be  feared  in  the  future.  It 
is  well  now  to  make  the  patient  hold  his  breath — first  at  the  end 
of  deep  inspiration,  and  secondly  at  the  end  of  deep  expiration. 
Should  the  abnormal  sound  be  heard  at  one  of  these  periods,  and 
entirely  disappear  at  the  other,  or,  at  least,  be  materially  altered  in 
character  and  loudness,  it  is  probable  that  it  depends  on  the 
forcible  emptying  of  a  small  tongue  of  lung  tissue  by  the  mechanical 
pressure  of  the  heart  in  systole.  This  is,  however,  a  rare  sound  to 
hear. 

If  we  have  thus  decided  that  the  sound  has  its  origin  in  the 
cardiac  organs,  the  next  point  is  to  determine  whether  it  is  peri- 
cardial or  endocardial.  At  the  apex  of  the  heart  very  little  diffi- 
culty will  be  experienced,  for  the  to-and-fro  rubbing  of  pericarditis 
present  throughout  the  whole  cycle  of  the  heart's  action  is  very 
unlike  any  apical  endocardial  bruits,  and  the  galloping  rhythm  of 
a  rapid  heart  only  requires  a  little  careful  listening  to  distinguish 
it.  At  the  base,  where  pericardial  bruits  are  perhaps  more  common, 
the  difficulty  of  distinguishing  them  from  double  aortic  murmurs  is 
a  little  greater. 

The  following  table  correlates  and  contrasts  the  most  important 
distinguishing  features  in  all  cases : — 


Exo-  or  Pericardial  Sounds.       Endocardial  Sounds. 


Character. 


Time  of  occurrence. 


Conduction. 


Almost  always  a  fric- 
tion or  rubbing 
sound ;  practically 
never  musical. 

At  any  period  of  cycle, 
not  specially  with 
systole  or  diastole. 

Are  not  conducted 
along  the  blood 
stream  or  to  apex, 
though  they  may  be 
heard  over  a  wide 
area. 


More  usually  blowing 
in  character ;  often 
musical. 

Always  in  connection 
with,  if  not  actually 
at,  systole  or  dia- 
stole. 

Conducted  upwards,  or 
to  the  apex  and 
axilla,  except  pre- 
systolic bruits,  which 
have  such  special 
characteristics  as  to 
barely  allow  of  mis- 
takes. 


128 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Exo-  or  Pericardial  Sounds.        Endocardial  Sounds. 


Position   of  maximum 
intensity. 


Effects  of  pressure. 


Variation  from  day  to 
day. 


Pulse   and   associated 
symptoms. 


May  be  heard  any- 
where, but  where 
heard  do  not  gradu- 
ally lose  in  intensity 
on  gradual  shifting 
of  stethoscope. 


In  yielding  chests  firm 
pressure  is  likely  to 
cause  marked  altera- 
tion in  sound. 


Probably  vary  in  area 
from  day  to  day,  and 
may  disappear 
rather  rapidly,  but 
do  not  dodge  about, 
appearing  and  dis- 
appearing  alter- 
nately. 

Pulse  rate  sure  to  be 
accelerated  in  acute 
pericarditis  (in  chro- 
nic cases  no  rub 
because  of  adhe- 
sions, or  if  present 
is  pleuropericardial, 
vide  supra). 


Apex,  for  mitral  bruits, 
base  or  mid  ster- 
num,foraortic  bruits, 
are  points  of  maxi- 
mum intensity,  and 
the  bruits  gradually 
diminish  from  their 
point  of  greatest 
distinctness. 

Pressure  makes  no  real 
difference  in  the 
sound,  though  the 
closer  fit  of  the 
stethoscope  may  en- 
able it  to  be  heard 
more  distinctly. 

More  likely  to  be  con- 
stant, except  in  recent 
or  ulcerative  endo- 
carditis ;  they  have 
at  times  a  curious 
habit  of  appearing 
and  disappearing  in 
a  most  capricious 
manner. 

Pulse  rate  entirely 
dependent  on  the 
recentness  of  the  in- 
flammatory attack  or 
on  physical  condition 
of  patient,  so  that 
in  chronic  cases  it 
may  be  for  years 
quite  natural. 


Considerable  precision  may  thus  enter  into  our  decision  as  to 
whether  the  source  of  an  abnormal  sound  is  endo-  or  exocardial, 
but  when  we  come  to  consider  the  various  problems  connected 
with  unusual  sounds  of  endocardial  origin,  we  are  on  very  treacher- 
ous ground  indeed.  We  can  now  and  again  decide  some  of  them 
with  a  tolerable  degree  of  accuracy,  but  on  other  occasions  and 
for  other  problems  even  the  keenest  judgment  of  the  most  mature  ex- 
perience will  only  with  diffidence  and  hesitation  express  an  opinion. 


IV 


DISEASES  OF  THORACIC  ORGANS 


129 


Epitomised  and  tabulated  the  position  is  this : — 
I.  What  is  the  exact  origin  of  the  bruit? 

Blood  states,  poverty  of  blood,  either  of  quantity  or  quality. 


It  may  be 

due  to 


Organic    disease     oC] 
valves   obvious    to 
the  naked  eye  on 
post  -  mortem     ex- 
amination. 


^litral. 
Aortic. 
Pulmonary. 
Tricuspid. 


Leakage     of     valves^  I 

without  naked  eye  ^May  be  due  to  ^ 
changes.  J 

\  Aneurysm. 


Insufficiency  or  sten- 
osis, recent  inflam- 
mation or  effects 
of  old  trouble. 

[General  dilatation  of 


walls  of  cavities,  or 
improper  or  feeble 
action  of  individual 

musculi  papillares. 


2.  What  is  the  vital  significance  to  the  patient  of  the  bruit 
thus  detected? 

Here  I  shall  attempt  only  a  complete  solution  of  some  of  the 
simpler  problems,  with  an  indication  of  the  principles  that  must 
guide  us  in  attempting  to  decide  the  more  complex  ones. 


^.— WHAT  IS  THE  EXACT  ORIGIN  OF  THE  BRUIT? 

(a)  Hccmic  v.  Organic  Bruits 

It  is  usually  comparatively  easy  to  determine  whether  a  bruit  is 
due  to  poverty  of  the  blood — ordinarily  termed  hsemic  bruits — 
though  the  precise  cause  of  such  bruits  is  a  matter  of  very  great 
dispute  and  uncertainty ;  Dr.  Byrom  Bramwell  offering  us  a  choice 
of  (i)  pulmonary,  (2)  mitral,  (3)  left  appendicular.  Whatever  its 
cause,  the  following  particulars  will  suffice  to  separate  it  from 
bruits  owning  a  definite  organic  lesion  as  causative  factor : — 


Position. 


If  of  Haemic  Origin. 
Rarely  heard  at  the 
apex,  and  if  so,  not 
conducted  into  axilla  ; 
usually  heard  at  the 
base,  and  better  a  little 
to  the  left  of  the  ster- 
num. 


K 


If  of  Organic  Origin. 
Heard  at  apex,  and  often 
conducted  into  axilla  ; 
basic  organic  bruits  are 
almost  always  better 
heard  a  little  to  the 
right  of  the  sternum ; 
pulmonary  organic 

bruits  being  rare,  ex- 
cept as  congenital  con- 
dition. 


I30 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Time. 


Character. 


Conduction. 


Loudness  al- 
tered. 


Associated  con- 
ditions. 


If  of  Hsemic  Origin. 

Always  systolic,  never 
diastolic  or  presys- 
tolic. 

Not  very  distinctive,  but 
they  are  never  regu- 
larly musical. 

Rarely  conducted  any 
distance  beyond  their 
point  of  maximum  in- 
tensity; somewhat  sud- 
denly cease  to  be  heard 
as  stethoscope  is  moved. 

Become  very  much  louder 
on  patient  lying  down 
on  the  back. 


Patient  obviously  anaemic, 
and  as  this  improves, 
the  bruit  is  likely  to 
disappear. 


If  of  Organic  Origin. 

May  be,  of  course,  sys- 
tolic or  diastolic,  or 
both,  or  presystolic. 

May  be  musical. 


Usually  conducted  some 
way  from  maximum 
point,  and  gradually 
die  away  in  intensity  as 
stethoscope  is  shifted. 

Not  markedly  altered  by 
patient  lying  on  the 
back  ;  any  alteration 
usually  in  direction  of 
diminution. 

Not  necessarily  anaemic  ; 
aortic  disease  is  most 
likely  to  cause  anaemia. 
This  anaemia  is  not 
likely  to  yield  to  treat- 
ment, and  if  it  does, 
the  bruit  still  persists. 


(b)    Valve  of  Origin  of  Bruits  of  Organic  Origin 

The  rules  commonly  laid  down  for  discriminating  the  various 
sources  of  bruits  due  to  organic  valvular  trouble  may  be  briefly 
indicated  as  follows  : — 


Mitral  systolic,  indi- 
cating regurgita- 
tion through  an  in- 
competent mitral 
valve. 


Mitral  presystolic, 
indicating  abnor- 
mal narrowing  of 
mitral  orifice. 


Systolic  in  time,  i.e.  aocompanying  or  replacing 
the  first  sound  ;  best  heard  at  the  apex,  con- 
ducted into  the  axilla  even  to  the  angle  of  the 
left  scapula  ;  pulmonary  second  sound  usually 
accentuated  ;  apex  beat  displaced  down  and 
out  in  old  standing  cases,  indicating  some 
degree  of  enlargement  of  the  left  side  the 
heart ;  pulse  small. 

Presystolic  in  time,  leading  up  to  a  sharply 
ceasing  first  sound  ;  best  heard  a  little  above 
the  apex,  not  conducted  very  far  from  its 
point  of  maximum  intensity  ;  pulmonary  second 


IV 


DISEASES  OF  THORACIC  ORGANS 


131 


Aortic  systolic,  indi- 
cating obstruction 
at  aortic  orifice. 


Aortic  diastolic,  in- 
dicating incompe- 
tent aortic  valves. 


Tricuspid  systolic, 
indicating  regurgi- 
tation through  in- 
competent valves. 


sound  very  accentuated  ;  apex  beat  if  dis- 
placed at  all,  chiefly  to  the  left — outwards — 
indicating  enlargement  of  the  right  side.  (If 
the  word  '  abrupt '  be  pronounced  with  a  very 
rolling  r  the  word  becomes  almost  onomato- 
poeic of  the  phenomena  to  be  appreciated  in 
connection  with  this  bruit.) 

Systolic  in  time,  best  heard  over  mid  sternum 
about  the  third  cartilage,  or  in  the  second 
right  space  ;  conducted  upwards  towards  the 
vessels  of  the  neck ;  apex  beat  displaced  in 
old  cases  farther  down  and  out  than  with  any 
other  bruit,  indicating  the  greatest  hyper- 
trophy of  the  left  ventricle  ;  pulse  small. 

Heard  with  or  replacing  the  second  sound,  best 
over  mid  sternum  opposite  the  third  cartilages 
or  in  second  space  on  the  right ;  conducted 
down  to  the  apex  or  to  the  ensiform  cartilage, 
and  so  conspicuously  as  to  be  sometimes  best 
heard  at  those  spots ;  apex  beat  displaced 
down  and  out,  again  indicating  a  great  degree 
of  enlargement  of  the  left  ventricle  ;  pulse 
peculiarly  collapsing  —  the  water-hammer  or 
Corrigan's  pulse. 

Systolic  in  time,  best  heard  over  the  right  ven- 
tricle, and  conducted  a  little  outwards  to  the 
right ;  ver\'  rare  except  in  the  later  stages  of 
heart  failure,  and  is  accompanied  with  a  venous 
systolic  pulse  in  the  neck ;  indications  of 
hypertrophied  right  ventricle  pushing  apex 
beat  outwards. 

Best  heard  to  the  left  of  the  sternum,  veiy  rough; 
conducted  upwards  to  the  left. 

Too  rare  to  notice  here. 


Pulmonary  systolic, 
or  stenosis  of  pul- 
monary orifice. 

Pulmonary  diastolic ; 
tricuspid  presys- 
toHc. 

In  many  cases,  if  used  with  discrimination,  these  rules  vriSS.  give 
tolerably  accurate  results,  and  are  sufficiently  useful  to  be  remem- 
bered ;  but  even  in  the  most  competent  and  careful  hands  they 
are  apt  to  mislead,  for  statistics  have  shown ^  that  "out  of  every 
hundred  hearts  we  listen  to,  in  thirty-six  the  bruits  will  give  us 
exact  information,  in  ten  they  will  lead  us  absolutely  astray,  and 

^  Thesis  for  M.  D.  Oxon.  based  on  some  700  autopsies. 


132  DIFFERENTIAL  DIAGNOSIS  chap. 

in  fifty-six  they  will  give  us  information  in  excess  or  defect  of  the 
truth."  The  matter  is  of  less  importance,  as  we  must  iterate  and 
reiterate  the  fact  that  every  heart,  with  (or  without)  bruits,  has  to 
be  judged  on  the  merits  of  its  muscle  power  and  energy,  and  not 
by  the  bruits,  the  patient's  condition  must  be  taken  as  we  find  it, 
and  not  as  one  deducible  from  a  theory  of  what  it  ought  to  be  by 
the  murmurs  present.  Of  all  factors  by  which  our  clinical  judg- 
ment is  influenced,  that  of  the  bruits  present  is  the  one  of  smallest 
weight. 

The  above  rules  will  equally  apply  to  bruits  arising  under  cir- 
cumstances which  lead  us  to  think  that  they  are  more  likely  due  to 
relative  incompetency  or  muscle  imperfections,  such,  for  instance, 
as  a  case  in  which  cardiac  failure  is  already  noted,  and  a  bruit 
becomes  audible,  unexpectedly  developing  under  observation  without 
pyrexia.  The  pathology  of  such  cases  will  be  touched  on  a  little 
further  in  a  subsequent  section  {vide  pp.  135  et  seq.). 

(c)  The  Bruits  of  Aneurysm  v.   Valvular  Disease 

We  have  already  (pp.  105  efseq.)  dealt  with  the  separation  of  aneu- 
rysms from  intrathoracic  solid  tumours ;  we  have  here  to  separate 
them  from  lesions  of  the  heart  itself.  Aneurysms  of  the  transverse 
or  descending  aorta  can  scarcely  give  rise  to  suspicion  of  valvular 
mischief.  The  tumour  and  bruits  and  other  local  indications  are 
too  far  removed  from  the  situations  where  enlargement  of  the  heart 
or  valvular  bruits  would  be  observed.  It  is  those  of  the  ascending 
arch  that  require  some  care  in  discrimination,  though  even  here 
the  presence  or  absence  of  implication  of  the  valves  is  of  more 
importance  than  the  presence  or  absence  of  an  aneurysm  as  such. 

The    bruit    of    aneurysm    is    most     The    bruit   of  valvular   disease    is 
frequently    systolic,    only    occa-  most    frequently    double,    occa- 

sionally      double,       practically  sionally     systolic     or     diastolic 

never  diastolic  only,   often  also  only  (very  rarely  found  to  have 

absent  altogether ;  rarely  con-  been  completely  absent  when 
ducted  very  far,  and  never  down  post-mortem  shows  gross  valvu- 
the  sternum.  lar  disease)  ;  usually  conducted 

a  good  distance,  and  often 
heard  down  the  sternum  or  at 
apex  of  heart. 

Then  the  question  of  associated  cardiac  enlargement  must  be 
considered.     My  experience  in   the  post-mortem  room,  in  agree- 


IV  DISEASES  OF  THORACIC  ORGANS  133 

ment  with  recent  observations,  tends  to  show  that  aneurysms  as 
such,  i.e.  when  so  situated  as  not  to  interfere  with  tlie  aortic  valves, 
have  but  little  influence  in  causing  hypertrophy  of  the  heart.  Aortic 
valve  disease,  on  the  other  hand,  is  the  especial  trouble  pre-emi- 
nently calculated  to  produce  hypertrophy  and  dilatation  of  the  left 
ventricle  ;  hence,  if  with  the  bruit  there  is  well-marked  enlargement 
of  the  heart,  the  probabilities  are  strongly  in  favour  of  valvular 
disease  ;  if  there  is  but  httle  or  no  evidence  of  such  enlargement, 
the  probabilities  are  in  favour  of  an  aneurysm  as  the  cause  of  the 
murmur.  Again,  if  there  be  a  dulness  extending  suspiciously  to 
the  right  of  the  sternum,  the  position  of  the  heart's  apex  beat  will 
give  us  help.  Should  this  be  displaced  outwards  much  more  than 
downwards,  it  is  probable  we  have  to  deal  with  an  enlarged  right 
ventricle  (lung  trouble  or  mitral  stenosis) ;  if  much  downwards  as 
well  as  outvrards,  aortic  valve  trouble  is  again  probable.  If  not 
very  materially  displaced,  aneurysm  again  is  strongly  suggested  (or 
soHd  tumour). 

It  has  to  be  admitted  that  the  general  conditions,  viz.  severe 
physical  exertion  over  long  periods,  alcoholic  excess,  syphilis, 
advanced  age  with  senile  degeneration,  renal  disease,  etc.,  which 
are  predisposing  factors  in  aneurysm,  are  equally  the  predisposing 
factors  in  primary  aortic  valve  disease  (the  valves  are,  in  fact, 
merely  a  part  of  the  aorta,  and  degeneration  with  aneurysmal  yield- 
ing may  occur  at  any  point),  so  that  it  is  by  no  means  an  unfrequent 
thing,  in  fact  I  think  it  is  a  rule  of  the  majority  of  cases,  that  when 
aneurysm  occurs  it  shall  be  associated  with  vah^ular  lesions,  and 
hence  it  is  frequently  impossible  to  exclude  the  aneurysm,  although 
we  have  positive  evidence  that  the  heart  is  affected.  The  diagnosis 
is  of  less  importance  in  that  the  condition  is  a  grave  one,  and  what 
is  likely  to  help  the  heart  is  likely  to  help  the  patient  to  bear  with, 
or  to  cure  the  aneurysm  if  it  exists. 

^.— WHAT  IS  THE  VITAL  SIGNIFICANCE  TO  THE 
PATIENT  OF  THE  BRUITS? 

This  includes  two  problems,  the  first  of  which,  viz.  the  bruit  as 
an  indication  of  the  condition  of  the  muscle  of  the  heart,  has  really 
more  to  do  with  prognosis  than  diagnosis ;  it  has  already  been 
touched  upon  in  dealing  with  the  symptoms  that  suggest  morbus 
cordis,  and  will  be  further  considered  {vide  pp.  135  etseq.);  the  second 
is  the  bruit  as  a  direct  indicator  of  leakage  or  stenosis,  and  the 


134  DIFFERENTIAL  DIAGNOSIS  chap. 

influence  of  these  on  the  patient's  condition ;  this  we  will  now  con- 
sider. 

Bruits  of  hsemic  origin  may  certainly  be  ignored  in  cardiac 
pathology.  They  are  accidental  phenomena  in  diseases  of  other 
origin,  and  disappear  with  the  disappearance  of  the  blood  dys- 
crasia,  and  their  significance  is  nil  beyond  the  significance  of  this 
dyscrasia. 

Bruits  of  aneurysmal  origin,  too,  have  the  significance  of  the 
aneurysm  itself.  They  add  nothing  to  our  knowledge  of  the  course 
the  arterial  disease  will  take ;  they  give  no  guidance  in  treatment, 
and  their  disappearance,  if  they  do  disappear,  does  not  necessarily 
mean  the  cure  or  amelioration  of  the  condition.  This  work  does 
not  deal  with  treatment,  but  I  cannot  refrain  from  putting  on 
record  an  emphatic  protest  against  any  extremes  of  active  treatment 
in  aortic  aneurysms,  such  as  starvation  and  severe  bleedings.  The 
lesion  is  one  that  will  kill  quite  fast  enough  without  our  assistance, 
and  our  efforts  had  better  be  directed  to  making  life  bearable  by 
counsels  of  moderation  in  all  things  than  to  rendering  miserable 
the  remaining  years  of  a  threatened  life. 

Bruits  of  undoubtedly  organic  valvular  origin  have  the  following 
significations : — 

(i)  To  determine  the  presence  of  recent  inflammation  {vide 
p.  ii6). 

(2)  To  determine  excessive  dilatation  of  a  chamber  {vide  p. 
122). 

(3)  By  their  disappearance  to  determine  muscular  weakness 
{vide  p.  140). 

(4)  To  determine  single  or  combined  alterations  of  old  stand- 
ing in  the  valves,  with  their  significance. 

This  last  (4)  is  the  problem  to  the  decision  of  which  I  devoted 
some  time  ago  a  very  considerable  amount  of  statistical  inquiry. 
Omitting  the  actual  figures,  the  tables  I  prepared  showed  that,  sup- 
posing the  patient  died  from  the  effects  of  heart  disease — 

{a)  Mitral    incompetency    gives,    amongst    single    lesions,    the 

worst  prospect  of  prolonged  life. 
{b^  Aortic  incompetency  also  amongst  single  lesions  gives  the 

best  prospect. 
{c)  The  question  between  aortic   stenosis   and   mitral  stenosis 

depends   on   other  factors   to   such   an   extent  that  the 


IV  DISEASES  OF  THORACIC  ORGANS  135 

isolated  lesion  is  of  very  small  importance,  and  probably 

the  prospects  are  about  equal, 
(d)  If  aortic  stenosis  be  combined  with  mitral  incompetency, 

the  patient  gains  about  three  and  a  half  years  of  life  from 

what  he  would  enjoy  with  aortic  stenosis  only. 
{e)  Mitral  stenosis  combined  with  aortic  stenosis  is  a  very  fatal 

combination ;  but  if  the  pulmonary  or  tricuspid  be  also 

stenosed,    the   patient   gains   about   seven   years   of   life. 

Such  a  marked  difference  points  strongly  to  the  lung  as 

the  weak  spot  in  heart  disease. 

These  results,  at  any  rate  the  first  one  (which  seemed  to  be  the 
most  firmly  established  by  figures),  are  so  startling  and  so  contrary 
to  what  is  apparently  one's  general  experience  of  the  innocuousness 
of  a  mitral  systolic  bruit,  that  I  was  then  (1890),  and  still  am,  driven 
to  the  conclusion  that  they  illustrate  more  forcibly  than  any  other 
argument  the  futility  of  attempting  to  lay  any  weight  on  the  nature 
of  the  bruits  in  estimating  the  value  or  power  of  a  heart  whose 
valvular  machinery  is  damaged.  I  leave  them,  without  further  com- 
ment, to  be  refuted  or  corroborated  by  future  investigators. 


HEART  DISEASE  IRRESPECTIVE  OF  MURMURS 

In  discussing  hitherto  the  pathology  of  cardiac  disease  and 
hypertrophy  and  dilatation,  we  have  had  in  mind  chiefly  chronic 
organic  disease  of  the  valves  as  the  essential  cause  of  the  disturb- 
ance. It  is  certain  that  the  nervous  and  muscular  mechanisms, 
connections,  and  structures  are  capable,  in  an  otherwise  fairly 
healthy  individual,  of  obviating  to  an  almost  complete  extent,  and 
for  a  very  long  time,  such  defections  in  valve  arrangements ;  but  if 
the  patient  is  to  die,  as  many  do  (though  very  many  do  not)  from 
chronic  valvular  trouble,  a  time  eventually  arrives  for  him  when 
such  compensation  fails  from  malnutrition  or  overstrain  of  muscle 
(?  of  nerve  too).  The  case  then,  from  its  causation,  goes  into  a 
special  group,  but  from  its  clinical  features  remains  an  illustration 
of  the  class  of  cases  which  we  must  now  consider,  viz.  those  in 
which  the  nervous  or  muscular  mechanisms  have  broken  down,  or 
possibly  (as  in  valvular  trouble  ?)  both  have  given  out.  The  precise 
pathology  of  the  various  examples  of  this  class  is  often  most  obscure, 
and  probably  the  essential  elements  in  it  vary  from  time  to  time, 
now  nerve,  now  muscle  being  at  fault.     So  far  as  can  be  understood, 


36 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Muscular  defects 
of  degeneration 
(whether  fatty 
or  fibrous  or 
other  is  not  ■< 
very  material ; 
the  muscle  is 
no  longer  nat- 
ural). 


Nervous  influ- 
ences or  de- 
fects. 


Of  slower  onset 
through  months 
and  years. 


I  think  the  following  table  represents  fairly  completely  the  causes 
which  may  be  at  work  in  producing  the  clinical  features  of  the  case: — 

Malnutrition  from  the  circulat- 
ory disturbances  in  the  heart 
itself,  of  valvular  disease ; 
common. 

Malnutrition  from  more  general 

conditions,  e.£:  age,  vascular 

degeneration,  kidney  disease, 

J       gout,  obesity,  etc.  ;  common. 

Definite  new  growths,  syphilis, 
tubercle,  malignant  disease, 
hydatids,  etc. ;  all  are  rare. 

Fibrosis  or  scar  formation  from 
any  cause,  especially  peri-  or 
endocarditis,     syphilis,     etc. ; 
also  common,  at  any  rate  as 
revealed  by  the  microscope. 
'  Acute  febrile  disease,  especially 
perhaps  pneumonia,  typhoid, 
and  septicemia  (from  pyrexia, 
or  toxins,  or  both).     Poisons, 
<{       such  as  tobacco,  alcohol,  etc., 
which  may  affect  the  muscle 
as  well  as  the  nerves.     (This 
group  may  come  on  more  in- 
sidiously.) 
'  From    diseases    of    any    organ, 
Purely  reflex.         \      e.g.  intestines,  stomach,  ovary, 
etc.  (?  thyroid). 

Pressure  on  peripheral  part  of 
nerves,  enlarged  glands,  e.g. 
central  pressure  of  tumours, 
meningitis,  etc. 

Loss  of  control  of  nerves  from 
actual  neuritis  or  smaller  de- 
■l       gree  of  nerve  illness. 

Poisons — tobacco,  alcohol,  prob- 
ably thyroid  secretion,  etc. 
Diphtheria,  influenza,  and 
other  specific  diseases  prob- 
ably should  also  be  placed 
here. 


Of  more  rapid 
onset,  possibly 
days  or  weeks. 


Direct  effects  on 
vagi  or  acceler- 
ators. 


IV  DISEASES  OF  THORACIC  ORGANS  137 

The  clinical  features  of  the  cases  are  as  varied  as  the  possible 
causations.  Sometimes  they  assume  the  shape  of  the  most  dangerous 
and  serious  illnesses  we  can  meet  with ;  sometimes,  on  the  other  hand, 
they  indicate  but  a  trivial  malady ;  yet  the  former  may  prove  of  no 
moment,  while  sudden  death  may  terminate  the  latter.  They  may 
present  all  the  general  indications  of  back  pressure,  or  they  may 
confine  themselves  almost  entirely  to  local  pain  and  distress.  Diag- 
nosis becomes  increasingly  difficult  with  the  absence  of  indubitable 
signs  of  organic  disease,  and  mistakes  must  constantly  occur  even 
to  the  most  experienced.  Still,  a  careful  inquiry  into  the  history  of 
the  case,  and  an  equally  careful  weighing  and  balancing  of  all  avail- 
able factors  must  be  undertaken,  and  will  help  us  materially  in,  at 
any  rate,  basing  our  opinion  on  a  sound  foundation  of  probability, 
beyond  which  clinical  medicine  can  rarely  go ;  certainty  is  rarely 
attainable  where  the  exceeding  delicacy  of  ill-understood  physio- 
logical balances  is  in  question. 

It  may  be  laid  down  as  a  general  rule  (not  perhaps  without  some 
very  grave  exceptions — vagus  neuritis,  for  example,  after  diphtheria) 
that  affections  of  the  nerve  apparatus  are  less  serious  in  their 
outlook  than  those  of  the  muscle.  Remembering  how  easily  the 
heart  beat  is  affected,  at  least  in  frequency,  by  every  passing 
mental  shock,  by  pain,  by  gastric  disorder,  by,  in  short,  reflex  in- 
fluences from  every  quarter,  the  general  truth  of  this  rule  in  practice 
must,  I  think,  be  accepted.  Hence  our  first  efforts  at  diagnosis 
should  be  directed  to  an  endeavour  to  determine  on  which  side 
weakness  lies.  The  following  paragraphs  in  parallel  columns  will 
show  the  points  of  distinction  more  clearly,  and  bring  them  into 
sharper  contrast. 


DERANGEMENTS  OF  THE  DERANGEMENTS  IN  THE 

NERVOUS  CONTROL  MUSCLE  APPARATUS 

Points  in  the  Previous  History 

If  previous  attacks  of  symptoms  Previous  attacks  of  symptom  have 
have  occurred,  they  have  prob-  probably  not  cleared  up  entirely, 
ably  cleared  up  entirely,  leaving  but  have  left  permanent  short- 
no  trace  of  permanent  and  per-  ness  of  breath  or  other  evidence 
sistent  signs  of  ill-health.  They  of  ill-health.  They  were  prob- 
were  not  associated  with  decided  ably  associated  with  definite 
evidence  of  back  pressure  effects.  signs    of    back    pressure.       In 


I -.8 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


The  first  attack  was  probably 
associated  with  some  mental 
shock  or  dyspeptic  trouble,  or  if 
with  a  definite  illness,  it  was 
more  likely  influenza  or  diph- 
theria (both  known  to  cause 
nerve  changes)  than  rheumatism 
or  scarlet  fever,  etc.  (known  to 
produce  endo-  or  myocarditis). 
Attack  more  likely  to  be  quite 
sudden  in  onset,  without  obvious 
exciting  cause. 


young  people  the  first  attack 
traceable  to  rheumatism  or  other 
disease  known  to  produce  organic 
changes  in  endo-  or  myocardium. 
In  elderly  patients  there  will 
probably  be  found  an  admission 
of  progressive  feebleness  and 
shortness  of  breath  previous  to 
an  actual  attack  of  symptoms 
calling  for  medical  aid. 


Points  in  the  Symptoms  Complained  of 


More  likely  to  be  stress  laid  on 
the  local  symptoms,  pain  more 
or  less  sudden  and  spasmodic  in 
the  cardiac  area  (rapidly  sub- 
siding after  eructations  or  vomit- 
ing), palpitation,  fluttering  sen- 
sations, choking,  etc.,  also  pro- 
minent, but  soon  subsiding. 
Likely  enough  to  return  on  a 
repetition  of  the  recognised 
cause,  e.g.  heavy  meal,  tobacco, 
alcohol,  etc.  Faintness  is  again 
a  very  common  phenomenon  in 
such  cases,  but  fatal  syncope 
extremely  rare. 


Local  symptoms  less  prominent, 
and  usually  masked  by  the 
general  distress.  If  they  are 
prominent  there  is  no  doubt 
about  their  genuine  severity 
(angina,  vide  p.  1 1 3),  and  they  do 
not  subside  suddenly  after  mere 
eructation  or  vomiting.  Exciting 
cause  much  more  frequently 
physical  exertion  of  some  kind, 
or  very  violent  excitement. 
Faintness  of  an  ordinary  char- 
acter is  not  common,  but  fatal 
syncope  is  fairly  frequent. 


Points  ascertained  by  Examination  of  the  Patient 

General  Considerations  and  Conditiofts 

Age. — In  the  young  the  two  great  causes  of  cardiac  mtisde 
weakness  are  valvular  trouble  (congenital  or  acquired)  and  acute 
pyrexial  disease.  If  these  two  can  be  excluded,  cardiac  complaints 
in  younger  subjects  are  almost  certainly  nervous  in  origin.  In 
older  patients,  when  their  complaints  may  point  to  a  cardiac  source, 
we  are  much  more  anxious  about  the  condition  of  the  muscle. 
This  anxiety  will  be  increased  very  much  by  evidence  of  renal 
disease  or  arterial  degeneration.  The  latter,  in  fact,  is  a  better 
gauge   of  age  than   the   calendar's  tale  of  years.     The  coronary 


IV  DISEASES  OF  THORACIC  ORGANS  139 

arteries  so  frequently  share  in  this  degeneration  that  a  degenerate 
radial  or  temporal  is  an  absolute  bar  to  our  regarding  lightly  any 
history  of  ca?-diac  attacks ;  they  compel  a  serious  view  being 
taken  of  such  a  case.  Fatal  angina  or  an  aneurysm,  otherwise 
undiscoverable  but  with  a  gloomy  outlook,  must  inevitably  occur  to 
our  minds  under  such  circumstances.  In  later  life,  too,  one  is 
inclined  to  look  more  favourably  on  the  same  symptoms  in  a  woman 
than  in  a  man. 

Sex. — Of  sex,  apart  from  age,  but  little  can  be  said.  Women, 
as  a  rule,  are  certainly  more  hable  than  men  to  view  with  appre- 
hension slight  symptoms  or  disquieting  sensations  in  the  cardiac 
region ;  hence,  if  there  is  no  obvious  origin  for  heart  disease,  one 
would  be  more  inclined  in  a  woman  towards  a  neurotic  explanation 
of  a  case.  If,  on  the  other  hand,  ob\dous  hysterical  manifestations 
of  other  kinds  are  present  —  Grave's  disease,  influenza,  tobacco, 
alcohol,  sexual  indulgence,  masturbation,  puberty  with  its  strain  on 
the  system,  a  neurotic  heredity — if  any  one  of  these  gives  us  a  clue, 
sex  at  once  becomes  of  very  little  account  in  comparison  with  such 
indication. 

Back  Pressure  Effects. — These  we  have  already  (p.  118)  considered 
in  some  detail.  For  our  present  purposes  we  may  divide  them  into 
— (i)  disturbances  of  function;  (2)  disturbances  of  structure — 
oedema,  fibrosis,  etc. — and  we  may  state  that — 

In  ner\-ous  affections  of  the  heart  In  muscular  troubles  both  classes 

the      latter     class      is      seldom  are   common,    and,    indeed,    the 

(?    never  —  vagus    neuritis,    for  characteristic  feature.     Provided 

example)     seen.       Evidence    of  there    is   no   local   cause    for    a 

the  former  class   is   fairly  com-  member  of  the  second  class,  its 

mon  :   shortness  of  breath  with-  occurrence  is  practically  patho- 

out  rales    or    bloody  expectora-  gnomonic  of  heart  muscle  failure, 
tion,     disturbances     of     general 
cerebration,  or  of  special  senses, 
or  irritability  of  stomach,  etc. 

Local  Examination  of  the   Cardiac  Region 

Inspection.,  palpation.,  zxid  percussion  are  only  of  essential  utility  in 
determining  the  presence  or  absence  of  hypertrophy  and  dilatation, 
and  as  one  indication  of  frequency  and  irregularity. 

Hypertrophy  and  Dilatation.,  either  or  both 

In  purely  ner\-ous  affections  of  the      In  m.uscular  troubles  alteration  in 
heart    the    organ    is   but    rarely  the  size  of  the  heart  is  constant 


140 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


much  larger  than  normal.  The 
chief  exception  is  long-standing 
Grave's  disease. 


except  in  acute  febrile  disorders 
(on  the  presence  of  which  the 
diagnosis  mainly  rests).  This, 
in  fact,  when  marked,  constitutes 
the  type  case. 


Frequency  and  Irregularity 


Tachycardia  and  bradycardia  are 
the  commonest  features  in 
nervous  affections  of  the  heart. 
In  fact,  either  of  them,  possibly 
with  some  irregularity,  but  with- 
out other  objective  signs  of  heart 
disease^  constitutes  the  type  case, 
and  under  such  circumstances, 
in  combination,  a  pulse  of  over 
160  or  under  50  may  safely  be 
regarded  as  due  to  nervous  in- 
fluences. 


Tobacco  in  excess,  Grave's  disease, 
influenza  are  the  common  causes 
of  such  tachycardia  and  palpita- 
tion, and  careful  inquiry  must 
be  made  for  them. 


In  the  more  slowly  developing 
defects  of  muscle,  frequency 
rarely  rises  much  beyond  130 
without  at  the  same  time  being 
associated  with  marked  tumul- 
tuous irregularity  and  signs  of 
back  pressure ;  nor,  on  the 
other  hand,  is  it  often  reduced 
below  60  without  similar  indica- 
tions. In  the  more  rapidly 
developing  muscle  failure  of 
poisons  and  pyrexia  frequency 
may  be  very  high  without  such 
other  symptoms,  but  then  the 
feebleness  of  the  sounds  is  our 
best  guide. 

Irregularity  alone  as  the  sole  indi- 
cation of  muscular  trouble  never 
occurs,  at  any  rate  for  long. 
Should  it  be  the  first  warning 
others  will  very  soon  appear. 


Vide  frequency  also  (on  p.  124)  under  Hypertrophy  and  Dilata- 


tion. 

Bruits. — In  nervous  troubles  bruits 
of  any  kind  are  exceedingly  rare, 
and  still  rarer  is  it  to  find  one 
that  follows  the  rules  laid  down 
for  those  of  valvular  origin, 
though  I  think  it  probable  that 
some  of  the  obscurer  murmurs 
may  be  due  to  irregularity  of 
nerve  influence  on  individual 
muscle  bundles. 


The  presence  of  bruits  in  muscle 
troubles  has  already  been  dis- 
cussed (p.  1 1 6).  Here  we  need 
only  mention  that  the  disappear- 
ance of  a  valvular  bruit  with  in- 
crease in  severity  of  symptoms 
is  pathognomonic  of  muscle 
failure,  as,  indeed,  is  its  first 
appearance  under  such  cir- 
cumstances of  increase  in  symp- 
toms. 


IV 


DISEASES  OF  THORACIC  ORGANS 


141 


The  Ordinary  Cardiac  Sounds 
Nervous    affections    of  the    heart     Muscle  troubles,  on  the  other  hand, 


have  a  peculiar  tendency  to 
render  the  sounds  sharper  and 
more  distinct  as  noises,  though 
the  contrast  between  the  first 
and  second  may  be  lost  in  ex- 
treme frequencies.  If  any  sound 
disappears  in  nerve  troubles  it 
is  the  second. 


have  a  tendency  to  shorten  the 
first  sound,  and,  at  the  same 
time,  to  render  it  less  audible. 
So  much  so,  that  in  some  cases 
of  poisoning,  prolonged  pyrexia 
(as  in  typhoid,  etc.)  or  fatty 
heart,  the  first  sound  may  be- 
come almost  inaudible.  This  is 
true  whether  bruits  are  present 
or  not.  Their  presence  only 
renders  its  appreciation  more 
difficult. 


Such,  in  detail,  are  the  individual  points  requiring  attention  in 
the  diagnosis  of  the  nature  and  meaning  of  cardiac  complaints.  In 
practice  the  difficulty  lies  not  so  much  in  estimating  these  sepa- 
rately as  in  weighing  them  collectively  and  striking  a  balance 
between  those  which  point  in  opposite  directions.  It  is  here  that 
clinical  experience  and  acumen  have  their  most  brilliant  oppor- 
tunities for  making  a  reputation  for  their  possessor,  and  no  hard 
and  fast  rules  can  replace  them.  The  only  advice  I  have  to  give  of 
general  application  is,  "  Don't  be  in  too  great  a  hurry  to  express  a 
decided  opinion.  Time  and  circumstances  will  often  throw  a  clear 
light  on  a  case  which  is  at  first  apparently  obscure  and  perplexing." 


ULCERATIVE  ENDOCARDITIS 

To  understand  the  diagnostic  problems  of  ulcerative  endocarditis 
it  is  necessary  to  enter  into  the  outlines  of  the  pathology  of  endo- 
carditis in  general.  The  four  following  postulates  constitute  the 
essential  foundations : — 

1.  That  acute  endocarditis  arises,  precisely  like  inflammation 
elsewhere,  as  the  result  of  an  irritant  applied  to  the  membrane. 

2.  That  the  severity  of  the  anatomical  lesions,  produced  by  the 
inflammation,  is  strictly  proportionate  to  the  relative  strength  of — 
on  the  one  side,  the  toxicity  or  nature  of  the  irritant ;  on  the  other 
side,  the  resisting  powder  of  the  membrane. 

3.  That  in  clinical  practice  the  irritant  is  always  either  chemical 


142  DIFFERENTIAL  DIAGNOSIS  chap. 

substances  produced  by  (i)  unnatural  metabolism  of  the  tissues,^ 
(2)  microbic  activity,  or  it  is  the  microbes  themselves  and  their 
activities  locally  exerted  on  the  membrane. 

4.  That  a  previously  damaged  valve  forms  a  locus  minoris 
resistenticB  to  the  influence  of  any  poison  circulating  in  the  blood. 

In  connection  with  postulate  (2)  and  our  knowledge  of  the 
anatomical  changes  that  ordinarily  accompany  any  inflammatory 
process,  we  may  tabulate  endocardial  changes  thus  : — 

Phenomena  of  constant  Phenomena  whose  occurrence  depends  on 
occurrence      at     the  circumstances  defined  by  postulate  (2). 

onset   in  every  case 
of  acute  endocarditis. 

'{a)  Simple  swelling  without  loss  of  epithelium, 
no  vegetations,  and  ultimately  complete 
resolution. 

Active  congestion,  with  \{b)  Swelling  plus  loss  of  epithelium  (micro- 
effusion  of  serum  and  j  scopic  ulceration)  ;  appearance  of  vegeta- 
cells  and  swelling  of  \  tions  ;  ultimately  some  thickening  or 
the  valve.                       J  scarring  left  behind. 

ic)  Swelling,  loss  of  epithelium,  vegetations 
plus  loss  of  other  tissues  and  naked  eye 
ulceration. 

{a)  Must  be  allowed  to  occur  in  those  cases  of  rheumatic  fever 
and  other  illnesses  in  which  a  definite  valvular  bruit  occurs,  but 
finally  entirely  disappears. 

Q})  Is  the  most  common  clinical  occurrence  in  such  illnesses 
(rheumatic  fever)  as  leave  a  permanent  organic  valvular  bruit. 
These  must  in  strictness  be  also  termed  ulcerative  endocarditis, 
but  as  the  loss  of  tissue  is  of  microscopic  proportions,  the  term  is 
usually  reserved  for  the  third  class. 

{c)  It  is  to  this  condition  that  the  term  ulcerative  endocarditis 
is  usually  applied.  I  have  put  it  in  serial  continuity  to  the  other 
forms  to  emphasise  what  I  believe  to  be  its  real  position,  viz.  an 
endocarditis,  the  severity  and  course  of  which  depend  upon  circum- 
stances which  may  be  called  accidental,  in  support  or  explanation 
of  which  statement  we  will  now  consider  the  clinical  occurrence  of 
severe  endocarditis. 

First  of  all,  cases  of  the  following  type  are  unfortunately  by  no 
means  rare.     A  patient,  probably  under  twenty,  is  attacked  wirh 

^  This  is  inserted  in  view  of  the  doubt  whether  rheumatism  is  a  microbic  disease 


IV  DISEASES  OF  THORACIC  ORGANS  143 

rheumatic  fever.  A  valvular  bruit  develops  and  persists,  but  the 
patient  becomes  more  or  less  convalescent  from  distinct  rheumatic 
symptoms.  Then,  without  any  pyrexia,  or  very  slight  and  tem- 
porary fever,  one  or  other,  or  perhaps  one  after  the  other,  some  of 
the  following  incidents  occur:  attacks  of  pain  in  and  swelling  of 
the  spleen,  renal  pain  with  haematuria,  cough  with  bloody  sputum 
and  a  pleuritic  rub,  cedema  with  loss  of  circulation  in  a  limb  or 
part  of  one,  hemiplegia,  etc.,  each  and  all  evidences  of  an  embolus 
being  swept  from  the  heart  into  the  organ  specified.  The  patient 
may  yet  live  on  in  an  invalid  condition  for  some  months,  and  even 
for  years,  and  eventually  succumb  from  cardiac  failure  or  from  an 
embolus  proving  fatal.  On  autopsy  we  find  the  areas  of  embolism, 
corresponding  to  the  symptoms,  each  and  all  in  what  may  be 
termed  a  quiescent  condition,  i.e.  one  the  ultimate  end  of  which 
will  be  simple  fibrosis  or  scarring  after  absorption  of  very  slightly 
irritating  dead  tissue.  We  find  on  the  valves  of  the  heart  a  greater 
or  less  amount  of  vegetations,  on  the  removal  of  which  losses  of 
substance — ulcers — may  be  plainly  visible  in  the  valve  tissue,  but, 
and  this  is  the  point,  from  neither  the  valves  nor  the  eiiibolised  areas 
can  any  growth  of  pathoge7iic  7nicrobes  be  obtained.  Such  a  case  must 
be  termed  severe — and  ulcerative — endocarditis,  though  its  origin 
is  purely  rheumatic. 

Now  let  us  sketch  the  other  form.  An  attack  of  rheumatic 
fever,  followed  by  the  appearance  of  a  bruit  as  before,  but  the 
patient  gets  quite  well  of  all  symptoms  and  remains  so,  a  murmur 
being  the  only  evidence  of  his  attack.  One  day  an  entrance  to  his 
system  is  effected  by  potent-for-evil  microbes,  and  now  follows  a 
train  of  symptoms  which  in  gross  may  be  termed  septicaemic — 
hectic,  sweating,  rigors,  diarrhoea,  ups  and  downs — and  quite 
probably  evidences  of  emboli,  as  in  the  previous  case.  The 
patient  dies,  not  of  an  apyrexial  exhaustion  or  cardiac  failure,  but 
evidently  of  some  acute  febrile  process.  On  autopsy  we  find,  not 
quiescent,  absorbing  embolised  areas,  hut  the  seat  of  each  embolus 
is  occupied  by  a  soft,  semi-purulent  collection  of  debris,  the  heart 
valves  or  endocardium  may  be  in  precisely  the  same  condition  to 
naked  eye  as  in  the  previous  case — though  it  is  probable  that  the 
loss  of  tissue  will  be  more  evident — vegetations  may  or  may  not  be 
equally  abundant,  but  from  the  ulcer  and  from  each  embolised  area 
can  be  obtained  a  culture  of  pathogenic  microbes.  Microbes  of  many 
kinds  have  thus  been  found — gonococci,  pneumococci,  pyogenes 
albus,  p.  aureus,  etc. 

The  difference  between  the  two  cases  is  clinically  real  enough 


144  DIFFERENTIAL  DIAGNOSIS  chap. 

and  serious  enough,  though  the  anatomical  changes  to  naked  eye 
may  be  practically  identical,  at  least  in  the  heart.  But  the  differ- 
ence is,  I  maintain,  a  quasi-accidental  one,  and  due  to  a  contamina- 
tion of  the  blood  by  virulent  microbes,  which  {vide  above)  may  be  of 
almost  any  kind,  and  hence  ulcerative  endocarditis  is  not  a  specific 
disease  to  the  same  degree  as  are  scarlet  fever,  syphilis,  or  small- 
pox, for  example.  It  is  more  like  pneumonia,  which  can  be 
produced  also  by  many  microbes. 

Diagnosis  of  Ulcerative  Endocarditis 

Septic  or  malignant  or  ulcerative  (they  are  all  used  synony- 
mously in  clinical  medicine)  endocarditis  is  either  endocarditis  plus 
blood-poisoning,  or  it  is  blood-poisoning  plus  endocarditis,  according 
as  the  valves  have  been  previously  or  are  now  only  for  the  first  time 
damaged.  Its  three  diagnostic  features  are:  (i)  symptoms  of 
blood-poisoning;  (2)  embolic  phenomena;  (3)  valvular  bruits — 
and  we  have  to  see  how  it  is  to  be  separated  from  the  diseases 
which  may  at  times  present  these  features. 

Simple  endocarditis,  by  which  we  must  here  understand  one 
from  which  recovery,  except  as  regards  scarring  of  the  valves,  is 
easily  possible  and  indeed  the  rule,  has  been  sketched  above,  and 
the  principal  point  of  difference  between  it  and  the  malignant  form 
is  the  absence  of  those  extreme  variations  in  temperature,  of 
diarrhoea,  and  of  rigors,  which  indicate  that  blood-poisoning  has 
been  superadded  to  the  valvular  trouble,  though  the  emboli  and 
the  murmurs  may  be  common  to  both. 

To  diagnose  septic  endocarditis  from  an  ordinary  case  of 
septicaemia,  no  matter  what  was  the  point  of  entrance  of  the 
poison,  is  a  work  of  supererogation ;  they  are  identical.  The  only 
point  is,  that  the  presence  of  a  bruit  renders  it  probable  that  the 
enemy  has  effected  a  lodgment  in  a  position — the  cardiac  valves — 
whence  his  spread  over  the  country  is  supremely  easy.  If  the 
bruit  materially  and  distinctly  alters  from  day  to  day,  we  have 
strong  proof  that  active  anatomical  changes  are  going  on  in  the 
valve — destruction  of  tissue  or  disposition  of  fibrinous  vegetations 
on  a  raw  surface — and  these  make  the  diagnosis  nearly  certain. 

But  there  are  still  three  specific  and  special  causes  of  toxaemia 
which  are  likely  to  cause  confusion.  These  are  typhoid  fever, 
acute  tuberculosis,  and  ague. 

Typhoid  fever,  in  its  pyrexia  and  in  its  diarrhoea,  may  resemble, 
and  is,   a  septic  disease;  per  contra^   a  person  with  old  valvular 


IV  DISEASES  OF  THORACIC  ORGANS  145 

trouble  is  not  thereby  protected  from  enteric,  and  in  such  a  person 
the  likeness  to  septic  endocarditis  may  be  very  close.  The  following 
differences  will,  however,  usually  help  us :  [a)  the  fever  in  typhoid 
is  usually  more  regularly  persistent,  not  so  intermittent  or  remittent 
in  its  type ;  (p)  the  abdominal  tenderness,  the  headache,  and  the 
rash  are  none  of  them  common  in  ulcerative  endocarditis ;  and 
lastly,  {c)  the  serum  (Weidal's  test)  test  for  typhoid  will,  with  almost 
mathematical  precision,  tell  us  whether  typhoid  is  or  is  not  present ; 
moreover,  (d)  if  a  bruit  is  present  in  a  patient  with  typhoid  alone,  it 
will  not  alter  from  day  to  day  in  any  marked  degree.  With  refer- 
ence to  this  last  point,  I  must  add  that,  in  my  view  of  the  pathology 
of  septic  endocarditis,  it  would  certainly  be  possible  for  typhoid  to 
relight  ulcerative  changes  in  the  valves. 

The  diagnosis  from  acute  tuberculosis  must  mainly  rest  on  the 
positive  evidence  of  this  disease  being  present — a  preponderance 
of  pulmonary  signs  and  symptoms,  proof  of  other  tubercular  lesions, 
etc.  If  a  cardiac  bruit  be  present,  it  must  be  watched  for  the 
same  indications  as  when  typhoid  is  suspected.  Too  often,  it 
must  be  admitted,  the  diagnosis  is  only  cleared  up  by  post-mortem 
examination. 

Malignant  endocarditis  has  been  mistaken  for  ague  only  by 
reason  of  a  temporary  regularity  in  the  rigors  and  pyrexial 
extremes.  The  effects  of  quinine  and  a  few  days'  delay  have 
never  left  the  matter  long  in  doubt,  unless  death  has  too  rapidly 
intervened. 

Many  cases  have  now  been  reported  in  which,  while  cardiac 
bruits  have  been  absent  during  life,  autopsy  has  revealed  the 
presence  of  (septic  ?)  valvular  lesions.  Of  such  cases  it  can  only 
be  said  that,  without  the  assistance  of  a  combination  of  septic 
symptoms  and  embolic  phenomena,  diagnosis  is  simply  impossible. 
We  can  only  guess  at  it  by  an  attempted  process  of  exclusion. 

Prognosis  in  Heart  Disease 

This  involves  two  separate  lines  of  thought.  First,  the  imme- 
diate prognosis  {a)  in  a  case  of  acute  endocarditis,  {b)  in  a  case  of 
cardiac  failure  without  evidence  of  acute  inflammatory  changes; 
secondly,  the  general  prognosis  of  a  case  of  chronic  cardiac  trouble 
as  regards  occupation,  etc. 

In  a  given  case  of  acute  endocarditis  the  prognosis  depends 
entirely  upon  the  severity  of  the  inflammatory  process,  and  the 
extent  to  which  it  weakens  the  muscle  by  its  spread.     The  deter- 

L 


146  DIFFERENTIAL  DIAGNOSIS  chap. 

mination  of  this  is  entirely  beyond  our  powers  of  direct  observa- 
tion ;  we  can  only  indirectly  estimate  it  to  some  degree  by  the 
symptoms  of  cardiac  failure,  and  prognosis  can  only  be  made  from 
day  to  day  by  noting  each  day's  progress.  When  the  temperature 
(rarely  much  raised)  becomes  quite  normal  we  have  a  right  to 
assume  that  the  active  stages  of  inflammation  are  at  least  not  pro- 
gressing, and  then  intensification  or  amelioration  of  back  pressure 
symptoms  gives  us  a  daily  despair  or  hope,  always  with  a  tendency 
to  look  on  the  bright  side,  because,  as  a  matter  of  clinical  experi- 
ence, it  is  but  rarely  that  acute — provided  that  it  is  not  septic — 
endocarditis  kills  directly.  Recovery  is  the  rule,  at  least  to  the 
extent  of  a  capability  of  leading  a  life  which  may  be  useful,  and 
even  enjoyable.  When,  as  in  repeated  attacks  of  acute  rheumatism, 
we  have  reason  to  believe  that  fresh  outbursts  of  inflammation 
keep  on  recurring,  the  outlook  must  necessarily  become  more 
gloomy  with  each  attack,  though  even  here  we  may,  to  a  large 
extent,  accept  the  above  suggestions. 

In  considering  those  cases  in  which  we  do  not  suspect  recent 
endocarditis,  whether  the  primary  trouble  has  originally  been  valvu- 
litis or  is  now  essentially  a  primary  muscular  degeneration,  the 
most  important  question  is.  What  is  it  that  has  caused  this  heart  to 
fail  710W ;  is  it  that  the  work  has  been  too  great  or  the  power  too 
small  ? — for  evidently  the  ratio  between  them  is  one  which  cannot  be 
maintained.  Careful  inquiry  must  be  made  into  the  duration  and 
progress  of  each  symptom,  however  trivial,  and  into  the  habits  and 
surroundings  of  the  patient ;  and  the  less  obvious  appears  the 
excess  of  work — we  must  never  forget  that  worry  or  anxiety,  mental 
work,  in  fact,  may  be  equally  or  more  detrimental  than  bodily 
exertion — the  more  anxious  are  we  lest  it  be  power  that  is  failing 
below  a  standard  compatible  with  prolonged  life.  When  we  have 
duly  weighed  the  items  of  this  consideration,  we  can  only  await 
next  the  verdict  of  treatment.  Statistics  of  bruits,  with  ages  at 
death,  are  but  of  httle  use.  As  age  or  degeneration,  i.e.  loss  of 
vital  elasticity,  advances  we  must  naturally  expect  a  slower  response 
to  remedial  measures,  if,  indeed,  response  be  not  entirely  absent ; 
but  even  now  it  is  astonishing  to  see  how  cases  may  improve  by  a 
judicious  combination  and  alternation  of  drugs  and  of  rest  and  in- 
creasing exertion.  The  latter,  though  an  obvious  common-sense 
method  of  treatment,  has  recently  been  brought  into  fashionable 
prominence  under  the  name  of  Schott  or  Nauheim  treatment. 

The  prognosis  of  other  cardiac  affections,  though  requiring 
frequently  the  nicest  of  judgment,  can  generally  be  regarded  with 


IV  DISEASES  OF  THORACIC  ORGANS  147 

lenient  eyes.  In  nervous  affections,  as  a  group,  the  outlook  is 
certainly  good,  and  the  patient  must  be  encouraged  to  live  an 
ordinary  life,  with  a  few  hints  as  to  the  avoidance  of  excesses  of 
mental  or  bodily  strain ;  and  if  a  cause,  such  as  tobacco  or  alcohol, 
can  be  discovered,  moderation  or  total  prohibition  must  be  en- 
forced. Even  when  associated  with  other  phenomena  of  Grave's 
disease,  a  rapid  heart  is  comparatively  harmless,  though  a  prolonged 
period  of  ill-health  must  be  accepted  as  inevitable. 

When  our  advice  is  asked  by  a  patient  who  has  recognised 
valvular  disease,  with  no  present  symptoms  of  failure,  we  must  look, 
and  encourage  the  patient  to  look,  on  the  cheerful  side  as  much  as 
possible.  Nothing  can  be  more  injudicious  in  such  cases  than  to 
pull  a  long  face  and  condemn  such  a  patient  to  a  life  of  idleness, 
ticketed  with  a  label,  "  Heart  Disease."  Habits  of  depressing  intro- 
spection are  sure  to  arise,  and  it  is  these  that  kill  more  surely  and 
rapidly  than  any  valvular  lesion.  Pregnancy  is  a  serious  considera- 
tion, but  I  have  known  a  girl  of  seventeen  with  severe  mitral  trouble 
of  rheumatic  origin  marry  at  twenty,  bear  eight  healthy  children, 
and  survive  till  the  age  of  seventy-seven.  In  questions  w^here  a 
possible  pregnancy  has  to  be  considered,  I  think  a  past  history  of 
back  pressure  symptoms  of  more  importance  than  the  present 
character  of  a  bruit. 


CHAPTER   V 

DIFFERENTIAL    DIAGNOSIS    OF    SOME    SYMPTOMS    AND    AFFECTIONS    OF 
NOSE,    THROAT,    AND    ALIMENTARY    TRACT    AND    ANNEXA 

HEMORRHAGE 

HAEMORRHAGE  may  appear  at  the  nose,  mouth,  or  anus  as  the  three 
natural  openings  of  the  system ;  but  it  may  originate  from  many 
situations,  and  we  shall  try  to  indicate  the  reasons  which  lead  us  to 
assign  to  it  its  actual  seat  of  origin. 

Epistaxis,  OR  Bleeding  from  the  Nose 

The  nose  differs  very  materially  from  the  mouth  and  anus  from 
our  present  point  of  view,  because  there  is  practically  no  difficulty 
in  ascertaining  that  the  blood  does  come  from  somewhere  in  the 
naso-pharyngeal  cavity  itself.  When  blood  makes  its  exit  from 
either  of  the  other  two  openings  the  question  of  precise  origin  is 
very  much  more  intricate,  as  we  shall  presently  see.  Only  as  the 
very  rarest  of  clinico-pathological  curiosities  could  one  imagine  a 
gastric  or  pulmonary  haemorrhage  giving  rise  to  more  than  a  pass- 
ing suspicion  that  the  naso-pharynx  was  its  seat,  and  very  Httle 
inquiry  into  the  mode  of  onset,  and  physical  examination  of  the 
cavities,  will  be  required  to  rapidly  settle  that  suspicion  should  it 
have  momentarily  arisen.  Consequently,  in  a  case  of  epistaxis  of 
some  duration  and  amount,  the  only  primary  questions  of  diagnosis 
that  can  arise  are  (i)  its  precise  seat,  and  (2)  its  cause. 

The  determination  of  question  (i),  though  often  difficult,  or 
even  impossible,  is,  if  it  be  necessary  at  all,  entirely  a  matter  of 
local  inspection  with  mirror  and  speculum,  and  will  not  be  further 


CHAP.  V        SOME  SYMPTOMS  AND  AFFECTIONS 


149 


considered.     The  answer  to  question  (2)  is  a  matter  of  the  very 
widest  clinical  importance,  and  we  will  proceed  to  classify  the — 


I.   Local     Causes :     in 
Nose,  etc. — 

(a)  Traumatism, 
fractured  base 
of  skull,  blows, 
etc. 

(d)  Adenoids. 


(c)  Malignant 

growth  or  in- 
nocent polypi. 

(d)  Ulcers,     lupus, 

syphilis,  etc., 
and  necrosis. 

(e)  Diphtheria  and 

similar  acute 
local  trouble, 
or  even  simple 
catarrh. 

2.   General      Constitu- 
tional Causes — 

(a)  Haemophilia. 


(3)   L  e  u  c  o  c  y- 
thsemia. 

(c)  Vascular      de- 

generation. 

(d)  Onset  of  acute 

fevers. 

(e)  Scurvy. 
(/)   Purpura. 
(g-)  Puberty. 


Causes  of  Epistaxis 

Diagnostic  Points. 

History  usually  obvious ;  difficulties  only  arise 
when  patient  is  drunk,  or  otherwise  no?z  C07n- 
pos  mentis  or  unconscious. 

Subject  a  young  child  ;  suspected  by  nasal  voice, 
sunken  bridge  of  nose,  habit  of  mouth  breath- 
ing ;  proved  by  inspection  ^vith  finger  and 
mirror. 

Subject  adult  probably ;  may  be  complaint  of 
local  pain,  and  of  nose  being  stuffed  ;  inspec- 
tion clears  up  the  case. 

Detected  by  speculum;  very  probably  associ- 
ated with  ozsena. 

History  of  illness  preceding  the  epistaxis,  and 
probably  other  local  signs,  sweUing,  etc. 


Invariably  (in  first  attack)  a  young  subject,  most 
likely  a  boy ;  history  of  previous  attacks  of 
hsemorrhage  markedly  disproportionate  to  the 
lesion,  e.g.  tooth  extraction,  etc. ;  family  his- 
tory sure  to  give  evidence  of  heredity. 

Probably  a  young  subject ;  examination  of  spleen 
and  blood  will  clear  up  the  case. 

Subject  old  (physiologically,  if  not  in  years) ; 
radials  thickened,  heart  hypertrophied  ;  pos- 
sibly also  renal  symptoms. 

Subject  young ;  obviously  out  of  health ;  ther- 
mometer proves  pyrexia. 

Swollen  and  spongy  gums. 

Always  (if  epistaxis)  purpuric  spots  elsewhere. 

Age  the  most  important  guide,  coupled  with  the 
knowledge  that  epistaxis  does  occur  frequently 
at  this  epoch  without  other  obvious  causation. 


I50 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


2.  General      Constitu-  Diagnostic  Points, 

tional  causes —  *= 

{h)  Vicarious    men-     Obviously  a  female,   and  with  a  history  of  sup- 
struation  (?).  pressed   natural   menstruation,  but   the    occur- 

rence of  well-established  cases  is  very  doubtful ; 
the  bleeding  would  be  periodical. 

These  causes,  as  well  as  those  which  follow,  emphasise  the 
absolute  necessity  of  a  careful  systematic  examination  of  a  patient 
with  epistaxis  if  the  diagnosis  is  not  at  once  obvious. 


;.   Local       Conditions 
other  than  Nasal — 

{a)  Distinct  kidney 
disease. 


{b)  Cirrhosis   of 

liver. 
{c)    Morbus  cordis. 

(^  Pregnancy. 

{e)  Coughing, 
sneezing,  etc., 
to  excess. 


Diagnostic  Points. 

This  is  only  a  slightly  special  branch  of  2  {c) 
in  which  the  kidney  trouble  is,  and  has  been, 
a  prominent  feature  in  the  case.  It  is  not 
absolutely  essential  that  contracted  kidney 
should  be  present.  A  consecutive  nephritis 
{q.v.)  will  sometimes  cause  it. 

History  or  other  strong  indication  of  alcoholic 
excesses  ;  liver  probably  enlarged. 

Bruits  present,  or  at  least  other  evidence  of  car- 
diac disease. 

An  occasional  cause  of  epistaxis.  History  and 
abdominal  examination  sufficient. 

History  distinctive ;  onset  after  such  excessive 
respiratory  movements. 


Differential  Diagnosis  of  Blood  issuing  by  the  Mouth 

Blood  which  issues  by  the  mouth  may  have  obviously  many 
sources : — 

1.  Naso-pharynx. 

2.  Mouth  and  pharynx. 

3.  Stomach  or  oesophagus. 

4.  Lungs. 

5.  Aneurysms  bursting  into  either  viscus. 

The  history  of  the  way  in  which  the  blood  comes  up  for  evacua- 
tion may  in  some  cases  be  sufficient  and  diagnostic,  but  even  in 
intelligent  adults  the  question  of  vomiting  v.  coughing  is  often  very 
difficult  to  settle,  so  that  the  differential  diagnosis  must  proceed  on 
definite  exclusion  lines  by  objective  guides  as  far  as  possible. 


SOME  SYMPrOMS  AND  AFFECTIONS 


151 


Our  first  care,  then,  must  be,  in  a  doubtful  case,  to  carefully  wipe 
away  the  blood  from  nose  and  mouth  and  fauces ;  a  careful  local 
examination,  with  thorough  exploration  with  eye  or  finger,  will  then 
soon  show  us  whether  the  blood  is  coming  from  above,  and  reference 
to  the  causes  of  epistaxis  will  probably  clear  the  matter  up  after  a 
systematic  examination  of  the  patient. 

N.B. — Do  not  be  led  away  from  a  careful  examination  of  nose 
and  throat  by  a  definite  history  of  haematemesis  i^q.v?)  or  haemo- 
ptysis {q.v.\  especially  if  other  symptoms  pointing  to  stomach  or 
lungs  are  absent. 

Suppose,  now,  that  local  examination  reveals  the  mouth  or  fauces 
as  the  seat  of  the  bleeding  vessel — the  following  conditions  must 
be  borne  in  mind  as  further  elements  in  the  exact  diagnosis : — 


Causes  of  Hemorrhage  from  Mouth  and  Fauces 


1.  Traumatism  from 

external    vio- 
lence. 

2.  Traumatism  from 

teeth  or  food. 


3.   Gums. 


4.  Ulcers. 


5.  Acute     tonsillitis 

and  pharyngitis. 

6.  Chronic    pharyn- 

Sfeal  conditions. 


Diagnostic  Points. 


History  obvious. 


Wound  found  on  gums,  tongue,  cheek,  or  fauces ; 
its  history  must  be  most  carefully  inquired  into, 
whether  consciously  done  by  the  teeth  or  dur- 
ing a  meal,  or  attack  of  coughing,  or  whether 
the  patient  is  unconscious  of  its  origin. 

A  bitten  tongue  with  no  history^  and  with  blood 
on  the  pillow  in  the  niorni7ig^  in  a  youngish 
subject  is  prima  facie  strong  presumptive  evi- 
de7tce  of  7ioctur7tal  epilepsy. 

Spongy,  from  scurvy  or  purpura  or  anaemia,  all 
of  which  will  show  definite  features  elsewhere. 
Gingivitis  in  dentition,  or  from  want  of  cleanli- 
ness in  mouth,  easily  recognised  by  age,  or  by 
tartar  encrustation. 

All  fairly  easily  recognised — malignant,  syphilitic, 
lupus,  tubercle,  or  simple  or  gangrenous  (can- 
crum  oris). 

Easily  recognised  by  dark  purplish  red  coloura- 
tion, or  by  actual  ulceration. 

Blood  only  in  spots  ;  dilated  and  varicose  veins 
seen  on  posterior  pharyngeal  wall. 


As  sources  of  haemorrhage  of  a  serious   degree  none   of  these 


152 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


require  much  consideration  beyond  mention  of  the  fact  that  any 
deep  or  progressive  ulceration  may  open  a  large  vessel ;  but  as 
sources  of  alarm  to  a  patient  they  have  a  very  great  and  real  im- 
portance, and  a  discovery  of  one  of  them  may  go  a  long  way  in 
establishing  a  reputation  for  care  or  carelessness. 

Leaving  the  mouth  and  parts  open  to  inspection,  we  have  now 
to  consider  those  seats  of  a  haemorrhage  appearing  through  the 
mouth,  which  are  out  of  sight.     These  are — 

1.  The  air  passages, 

2.  The  alimentary  tract, 

and  our  first  point  in  diagnosis  is  to  determine  which  of  these  two 
main  tracts  is  at  fault,  in  other  words,  to  distinguish — 


Sensation  accompany- 
ing the  voidance  of 
the  blood. 

Precedent  condition  of 
patient. 

Associated  condition 
of  patient. 


Voided  blood  itself. 


Associated 
mena. 


pheno- 


H^MOPTYSIS 

Cough  or  tickling  in 
throat,  or  possibly 
no  warning  at  all. 

Cough  or  known  lung 
mischief. 

If  pallor  present,  it 
came  on  subse- 
quently to  the  hae- 
morrhage, i.e.  the 
bleeding  excites 
cough  before  it  is 
sufficient  to  cause 
pallor. 

Usually  frothy,  and 
often  bright  (mix- 
ture c  air),  always 
alkaline. 

Melaena  not  marked 
as  a  rule ;  some  phy- 
sical signs,  rales, 
etc.,  possibly  found 
in  lungs.  N.B. — 
Their  absence 
does  not  exclude 
haemoptysis. 


V.         H^MATEMESIS 

Nausea  first,  followed 
by  act  of  vomiting 

Dyspepsia  or  marked 
gastric  disturbance. 

Pallor  often  precedes 
the  ejection  of  blood, 
i.e.  blood  pouring 
into  stomach  causes 
it  before  the  blood 
is  voided. 


Never  frothy,  usually 
dark,  and  frequently 
acid  from  admixture 
of  gastric  juice. 

Almost  certainly  fol- 
lowed by  melasna  ; 
possiblylocal  pain  or 
tenderness  over  ab- 
domen or  stomach. 
Caution  —  muscles 
may  be  tender  from 
coughing  or  strain- 
ing. 


Having  satisfied  ourselves  that  it  is  (i)  the  lung  which  is  the 
source  of  the  blood,  diagnosis  must  next  proceed  to  the — 


SOME  SYMPTOMS  AND  AFFECTIONS 


153 


Laryngitis,  trache- 
ites, bronchitis 
acute,  and  granu- 
lar pharyngitis. 


Pneumonia. 


Phthisis. 

Gangrene,     abscess 
bronchiectasis. 

Degenerative  bron- 
chitis and  em- 
physema. 

Foreign  body. 

Aneurysm. 


MaHgnant  growths. 


Blood  aspirated  into 
lung  in  hsemate- 
mesis. 


Causes  of  Hemoptysis 

Diagnostic  Points. 

If  within  reach  of  the  laiyngoscopic  mirror,  cause 
soon  cleared  up  (tubercular,  syphilitic,  or  malig- 
nant ulceration,  q.v.^  all  of  them  common  causes 
of  slight  hjemoptysis)  ;  blood  either  in  little 
pellets  or  thin  streaks  ;  sputum  very  sticky  and 
frothy;  pain  locally  on  swallowing  or  coughing. 

Sputum  usually  uniformly  stained  either  slightly 
or  up  to  prune -juice  colour,  very  sticky  and 
usually  nearly  or  quite  airless  ;  associated  dul- 
ness,  tubular  breathing,  and  temperature,  etc., 
commonly  distinctive  enough. 

Far  and  away  the  commonest  cause  of  profuse 
haemoptysis  ;  bacilli  if  found  distinctive,  but 
diagnosis  in  early  stages  often  impossible. 

All  rare  causes  of  haemorrhage  ;  associated  foetid 
smell  of  sputum,  and  local  physical  signs  char- 
acteristic. 

Condition  described  by  Sir  Andrew  Clark:  haemor- 
rhage fairly  free,  physical  signs  of  bronchitis 
and  emphysema,  without  any  distinctive  bacilli 
or  evidence  of  excavation  or  dilated  tubes. 

History  usually  sufficient  of  choking  with  aspira- 
tion of  the  foreign  body. 

As  a  cause  of  haemoptysis  rare,  but  when  aneur^^sm 
is  present  haemoptysis  is  tolerably  frequent ;  if 
other  signs  of  aneurysm  present,  haemoptysis 
adds  to  their  weight,  and  especially  if  there  are 
signs  of  pressure  on  a  large  air  tube.  N.B. — 
Slight  haemoptysis  may  precede  for  a  long 
period  the  actual  rupture  of  the  sac. 

Said  to  be  like  red-currant  jelly,  but  in  my  ex- 
perience the  haemorrhage  here  is  only  dis- 
tinguishable by  the  physical  signs  of  the  growth, 
and  has  nothing  distinctive  in  itself. 

Vide  tests  between  hsematemesis  and  haemoptysis ; 
if  definite  haematemesis  proved  to  be  present 
there  will  only  be  slight  pellets  of  blood  or 
blood-stained  mucus  coughed  up  for  a  few 
hours  or  a  day  or  so  after  the  vomiting. 


These  causes  really  fall  into  two  clinical  groups,  viz.  those  in 
which  the  source  and  cause  of  the  haemorrhage  are  obvious  or 


154 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


easily  detected,  and  those  in  which  probabiUties  have  to  be  nicely 
balanced.  To  the  former  group  belong  visible  laryngeal  and  pharyn- 
geal troubles,  obvious  gangrene,  abscess,  aneurysm,  pneumonia, 
and  carcinoma  secondary  to  an  obvious  primary  growth.  To  the 
latter  belong  those  cases  of  definite  haemoptysis  in  which  no  physical 
signs  at  all  are  to  be  found,  and  those  in  which  the  physical  signs 
are  those  of  bronchitis  plus  a  few  rales  and  fine  crepitations,  indicating 
the  present  situation  of  the  semi-coagulated  blood ;  in  this  group 
our  main  anxiety  is  the  determination  whether  phthisis  is  at  the 
bottom  of  the  matter  or  not,  and  the  question  will  be  found  dis- 
cussed under  that  heading  {vide  pp.  54  and  92). 

We  will  now  assume  that  (2)  the  blood  has  come  from  some  part 
of  the  alimentary  system.     We  have  to  consider  the — 

Causes  of  H^ematemesis 


Swallowed  blood 
(rarely  of  notice- 
able extent). 

Vicarious  menstrua- 
tion (very  rare). 

Bloodstates  in — 
Purpura, 
Scurvy, 
Yellow  fever, 
Acute  yellow 
atrophy  of 
liver,  etc., 
Traumatism. 


Gastritis    or    simple 
vomiting. 


Diagnostic  Points. 
« 
Already   considered ;    local    examination   usually 

sufficient  to  clear  up  the  case,  except  in  a  few 

cases  of  malingering,  with  deliberate  drinking 

of  blood. 

Of  very  doubtful  occurrence  ;  can  only  be  thought 

of  in  a  girl,  probably  young  and  hysterical ;  no 

other  local  symptoms,  periodicity  of  bleeding. 


All    rare    as   causes   of 
hsematemesis. 


The  condition  of  the 
patient  induced  by 
the  named  disease 
usually  quite  suffi- 
cient for  diagnosis. 


Aneurysm. 


History  sufficiently  obvious,  either  of  an  external 
blow  or  of  swallowing  a  corrosive  or  violent 
irritant,  or  some  mechanical  lacerator  of 
mucous  membrane. 

Haemorrhage  slight  as  a  rule,  and  usually  only 
in  streaks  ;  the  history  of  severe  vomiting  pre- 
ceding the  blood  usually  sufficient,  except  in 
those  cases  where  the  violence  has  actually 
ruptured  a  large  vessel ;  vide  below,  Aneurysm 
and  Ulcer,  etc. 

Quite  possibly  unrecognised  till  post-mortem  is 
made  ;     only    diagnosable    during    life    when 


SOME  SYMPTOMS  AND  AFFECTIONS 


155 


Cancer. 


Ulcer. 


Diseases  of  other 
organs  leading  to 
venous  conges- 
tion— 

(a)   Morbus  cordis. 

(i>)   Chronic  pulmon- 
ary disease. 

(c)  Cirrhosis  of  liver. 

(d)  Portal     conges- 

tion. 


Diagnostic  Poii 

previous  examination  has  revealed  a  tumour  of 
abdomen  with  expansile  pulsation,  Hccmor- 
rhage  very  profuse,  and  probably  rapidly  fatal. 

Haemorrhage  usually  of  coffee  ground  type,  great 
loss  of  flesh,  and  probably  a  tumour  ;  patient 
usually  beyond  early  middle  age. 

Haemorrhage  usually  free,  with  clots  ;  in  simple 
ulcer,  patient  usually  a  young  person  and 
more  commonly  a  female.  I  have  known  a 
tubercular  ulcer  in  a  phthisical  patient  cause 
fatal  hcemorrhage,  but  such  cases  are  very  rare. 


Presence  of  bruits  and  other  evidence  of  cardiac 

back  pressure. 
Evident  physical  signs  of  lung  disease,  associated 

with  failure  of  circulation. 
History   of  alcohol,   or   dyspepsia   and   vomiting 

suggestive  of  alcohol  ;  liver  enlarged  probably. 
Produced   by  ascites,   carcinoma  of  peritoneum, 

enlargement  or  diseases  of  spleen,  etc.,  with 

tolerably  obvious  features. 


Such  is  a  practically  complete  hst  of  the  causes  of  the  presence 
of  blood  in  the  stomach  leading  to  hsematemesis.  In  numbers 
they  look  formidable  enough  on  paper,  but  in  practice  they  are 
comparatively  simple  in  diagnosis.  Thus,  hemorrhage  from  the 
stomach  is  nez^er  the  first  and  totally  unexpected  symptom  of  serious 
bloodstates,  nor  of  those  forms  of  back  venous  pressure  commonly 
attributed  to  portal  congestion.  There  are  and  have  been  some 
prodromal  or  leading  indications  in  all  cases,  the  haematemesis 
forming  a  culminating  calamity,  so  to  speak,  not  perhaps  expected, 
but  not  altogether  unforeseen.  There  is  only  one  group  of  cases 
that  really  presents  much  difficulty,  viz.  those  in  the  middle  period 
of  hfe,  especially  in  men,  where  we  have  to  try  and  decide  between 
cirrhosis  of  the  hver,  carcinomatous  or  simple  ulceration,  and  an 
unexplained  cause  which  provisionally  may  be  termed  simple 
varicosity  of  veins.  More  than  one  such  case  has  occurred  to  me 
in  which  age  and  sex,  history  of  alcohol,  slight  dyspeptic  pheno- 
mena, and  the  entire  absence  of  positive  objective  signs  (enlarged 
liver,    tumour,    dilated    stomach,    etc.),    have    together   formed    a 


156  DIFFERENTIAL  DIAGNOSIS  chap. 

symptom-complex,  in  which  the  diagnostic  points  have  been  so 
nicely  balanced  that  a  positive  diagnosis  has  been  impossible  in  the 
absence  of  a  post-mortem.  Luckily  for  the  patient  the  diagnosis, 
from  a  therapeutical  point  of  view,  is  here  of  comparatively  little 
moment,  for  absolute  rest  in  bed,  combined  with  physiological  rest 
for  the  stomach,  constitute  the  main,  if  not  the  only  means  of  com- 
bating all  form  of  serious  gastric  haemorrhage.  For  some  further 
indications,  vide  under  the  headings  of  Ulcer,  Cirrhosis  of  Liver,  etc. 

Anal  Appearance  of  Blood 

We  must  now  consider  blood  passing  from  the  bowel  by  the 
anus.  It  may  be  laid  down  as  a  working  rule  that  blood  in  a 
comparatively  unaltered  state,  i.e.  recognisable  as  such  by  the  laity, 
passed  per  anum  comes  from  the  colon  or  rectum,  or  the  lowest 
two  feet  or  so  of  the  ileum.  Blood  coming  from  the  stomach  or 
upper  part  of  the  small  intestine  will  be  so  altered  by  the  digestive 
processes  as  to  appear  as  melaena  or  black  tarry  stools.  The  only 
exception  (it  occurred  to  me  once  in  tubercular  ulcer  of  the 
stomach,  verified  post-mortem)  is  a  case  in  which  the  bleeding  is  so 
profuse  as  to  practically  fill  the  intestine,  and  so  appear  at  the  anus 
simply  darkened  in  colour.     Such  cases  are  almost  invariably  fatal. 

The  following  are  the  Causes  of  Mel^ena 

Blood  passing  from     These    cases    constitute    an    enormous    majority 

the  stomach.  (probably   90  per  cent)  of  cases  of  melaena ; 

hsematemesis  is  very  likely  to  have  occurred  ; 

for  differential  diagnosis,  vide  table  above. 

Duodenal    ulcer,    or     Rare  as  causes  of  melasna  ;  suggested  chiefly  by 

simple,  tubercular,  the  presence  of  the  symptom  (melcena)  com- 

or  malignant  dis-  bined    with    the    absence    of    the     commoner 

ease  of  small  in-  causes  ;    possibly   some   tumour  felt   or    some 

testines.  abdominal    symptoms     suggesting    ulceration, 

but  not  of  a  gastric  type. 

Anchylostomiasis.  Very    rare    indeed    in    England    as    a    cause    of 

melaena  and  anaemia  ;  only  to  be  detected  by 
finding  eggs  in  the  faeces. 

Causes  of  Haemorrhage  (recognisable  as  such  by  the  Laity) 

PASSING  per  Anum 

A.    Lower  ileum—  Diagnostic  Points. 

Ulcers  :  Typhoid.      Haemorrhage   appearing  in  course  of  a  definite 

attack  or  of  a  vague  pyrexial  illness,  when  the 
hemorrhage  clears  up  the  diagnosis. 


SOME  SYMPTOMS  AND  AFFECTIONS 


157 


Tubercular. 


Dysenteric. 
Simple    and    car- 
cinomatous. 


Traumatism. 


Drugs,    especially 
violent  purges. 
Blood  conditions. 


Intussusception. 

B,  Csecum,  colon, 
and  sigmoid 
flexure. 


Diagnostic  Points. 

Usually  distinct  indications  of  tubercle,  but 
diagnosis  often  impossible,  ante  mortem,  from 
typhoid  ;  vide  Typhoid  v.  Tuberculosis. 

History  of  recent  or  old  dysentery  fairly  obvious. 

To  me  unknown  causes  of  severe  haemorrhage, 
but  might  conceivably  give  rise  to  the  symptom, 
but  would  not  be  diagnosable,  except  by  ab- 
sence of  above  three  troubles,  and  in  carci- 
noma possibly  a  tumour. 

History  of  a  blow  or  swallowing  a  foreign  body. 
If  such  a  case  arose  it  would  be  quite  a  patho- 
logical curiosity. 

History  of  administration. 

The  same  as  in  the  stomach,  but  all  rarer ;  occa- 
sionally has  occurred  as  a  sequel  to  the  very 
debilitating  scourge  of  influenza  ;  such  was  the 
cause  of  death  of  a  lately  deceased  distin- 
guished member  of  our  profession. 

Signs  of  intestinal  obstruction,  presence  of  strain- 
ing, etc. 

All  similar  causes  to  those  of  ileum,  but  dysen- 
teric and  carcinomatous  ulceration  are'  here 
very  common  causes  of  haemorrhage  instead  of 
being  rare,  while  the  reverse  is  the  case  with 
typhoid  and  tubercular  troubles,  intussuscep- 
tion commencing  in  colon  very  rare  indeed. 


C.  Rectum — 
Traumatism. 
Piles. 
Pol>^i. 
Prolapse. 

Intussusception  coming  do^^^l. 
Ulcers — dysenteric,     malignant, 

etc. 
Strictures. 

Fissures,  fistulae,  etc. 
Vaginal   sources,    to    be   looked 
for  in  females. 


All  within  reach  of  the  examining 
finger  or  speculum,  so  that  their 
diagnosis  requires  no  discussion  ; 
examination  of  the  rectum  also 
discloses  the  fact  that  the  blood 
does  come  from  the  lowest  six 
inches  of  the  bowel. 


Like    haemorrhage    appearing   by   the   mouth,    the    causes    of 
melsena   and   rectal    haemorrhage  are    much   more   formidable    on 


158  DIFFERENTIAL  DIAGNOSIS  chap. 

paper  than  in  practice,  and  it  is  but  very  rarely  that  some  clinical 
features  will  not  be  found  leading  unmistakably  to  a  definite 
diagnosis. 


VOMITING 

Vomiting  is  a  very  complex  process,  of  which  the  actual 
emptying  of  the  stomach  forms  only  a  culminating  objective 
feature.  According  to  physiology,  the  whole  series  of  phenomena 
ending  in  emesis  is  best  explained  by  the  hypothesis  that  there  is 
situated  in  the  medulla  oblongata  a  group  of  neuron  cells  (termed 
a  vomiting  centre),  the  dendrites  of  which  are  connected  with  the 
nervous  system  in  such  a  way  that,  on  the  one  hand,  they  may 
receive  afferent  impulses  from  any  part  of  the  body,  which  im- 
pulses are  capable  of  stimulating  them  to  special  activity,  and,  on 
the  other,  they  may  transmit  messages  to  the  salivary  glands,  to 
the  respiratory  mechanism,  and  to  the  voluntary  muscles  which, 
when  thus  stimulated,  produce  the  emptying  of  the  gastric  contents. 
By  accepting  this  explanatory  hypothesis,  we  are  in  a  position  to 
gain  a  more  or  less  rational  understanding  of  the  innumerable 
pathological  or  clinical  incidents  that  may  be  associated  with 
vomiting.  The  afferent  impulses  (as  from  a  crush  or  severe  pain, 
however  excited)  from  any  part  may  be  so  strong  as  to  cause  it, 
or,  on  the  other  hand,  the  condition  of  the  blood  circulating 
through  the  centre,  or  the  physical  condition  of  the  brain,  may  be 
such  as  to  independently  start  the  centre  into  action.  Lastly,  and 
far  most  frequently,  the  contents  or  condition  of  the  stomach 
itself  may  start  the  afferent  impulses. 

A  purely  scientific  or  physiological  analysis  of  vomiting  should 
therefore  start  with  a  division  into  central  or  direct,  and  peripheral  or 
reflex,  each  with  its  subdivisions;  but  from  a  clinical  and  diagnostic 
point  of  view  a  more  useful  classification  is  into  the  following : — 


SOME  SYMPTOMS  AND  AFFECTIONS 


159 


Causes  of  Vomiting 


Diagnostic  Indications 


/'Cerebral — 
Tumour. 
Meningitis. 
Cerebritis,  etc. 
General  shock. 


^ 


Gastric  crises  of 
tabes  dorsalis,  or 
G.P.I. 


Hysterical. 


Cardiac  disease. 

Pulmonary  diseases 
attended  by 
cough  —  phthisis, 
etc. 


Acute  Infective  dis- 
eases— the  zymo- 
tics,  pneumonia, 
etc. 

Ursemia  and  other 
kidney  troubles. 


Simple  pain. 


Not  usually  associated  with  much  nausea, 
independent  of  food  ;  almost  invariably  as- 
sociated with  marked  corroborative  evi- 
dence— optic  neuritis,  fits,  paralysis,  etc. — 
may  be  quite  intermittent  for  even  long 
periods,  and  then  its  apparent  causeless- 
ness  is  its  great  feature. 

Apparently  quite  causeless  in  its  onset,  and 
equally  mysterious  in  its  cessation  after  a 
day  or  two's  duration  :  also  independent  of 
food,  associated  with  more  local  pain  than 
cerebral  form. 

Probably  in  a  young  person,  and  one  who  is 
not  losing  flesh,  notwithstanding  the  asser- 
tion that  for  months  everything  has  been 
vomited. 

Distinct  evidence  of  bruits  and  back  pressure 
on  other  organs  than  the  stomach. 

On  inquiry  patient  will  say,  "  I  cough  till  I 
am  sick."  Physical  examination  rarely 
fails  to  show  good  cause  for  the  cough,  but 
it  is  astonishing  how  patients  will  complain 
of  the  vomiting  and  forget  the  cough  till  a 
leading  question  on  it  is  put  :  "  Are  you 
sick  because  you  cough,  or  are  you  sick 
independently  of  coughing  ?  " 

Although  vomiting,  especially  in  children,  is 
common  at  the  onset  of  febrile  acute 
illnesses,  it  must  be  very  rarely  that  the 
cause  is  not  soon  obvious,  for  the  ther- 
mometer will  rapidly  remove  doubt. 

Vomiting  again  causeless,  and  independent  of 
food ;  uiinary  examination  soon  clears  up 
the  case,  even  if  it  be  unattended  with 
commoner  symptoms  of  uraemia. 

Statement  made  by  patient  quite  sufficient. 


i6o  DIFFERENTIAL  DIAGNOSIS  chap. 

Pregnancy,    tumour,     Physical    examination  of  the  abdomen  very 
obstruction,  etc.  soon    clears    the    matter    up ;     abdominal 

pain  or  discomfort  usually  marked. 
Addison's  disease.         Vomiting   usually  associated  with    pain,  but 

the  accompanying  physical  weakness,   and 
especially  the  almost  imperceptible  pulse, 
will  point   to  the  disease  even  if  typical 
5  -<  bronzing  be  not  present. 

Gastric  trouble —  Vomiting     due     to    actual    disease    of    the 

Ulcers.  stomach  is,  broadly  speaking,  characterised 

Irritation.  by  being  in   some  definite  relationship  to 

Inflammation.  food  and  to  pain  or  discomfort  produced 

Pyloric      obstruc-  by  food. 

tion,  etc.  etc.  For  other  points  separating  the  various 

^         Poisoning.  gastric  troubles,  vide  Gastric  Ulcer,  etc. 

If  we  are  called  upon  to  investigate  a  case  of  vomiting,  very 
little  observation  is  required  to  eliminate  certain  of  the  above 
groups — the  pyrexia  and  aspect  of  acute  general  diseases,  the 
collapsed  features  or  the  history  of  obstruction,  the  evident  dropsy 
of  morbus  cordis,  the  pain  or  shock  of  an  accident,  etc.,  will  at 
once  put  even  the  most  careless  observer  on  the  right  track.  The 
diagnostic  difficulties  begin  when  the  vomiting  is  the  sole  obvious 
feature  that  attracts  the  anxious  attention  of  the  patient  or  of  the 
friends  in  the  case  of  children. 

In  quite  young  babies,  i.e.  in  the  first  year  of  life,  it  is  almost 
safe  to  conclude  at  once  that  food  and  consequently  gastric  irrita- 
tion, is  at  the  bottom  of  the  mischief,  though  we  must  not  forget  to 
look  for  signs  of  congenital  syphilis.  After  the  first  year  up  to,  say, 
puberty  the  insidious  onset  of  tubercular  meningitis  with  causeless 
vomiting  must  never  be  absent  from  our  minds,  however  obvious 
may  seem  at  first  sight  the  apparent  cause  for  the  symptom.  It  is 
also  during  this  period  of  childhood  that  all  acute  illnesses  are  apt 
to  have  vomiting  for  a  prominent  feature  in  their  early  stages,  from 
which  fact  we  may  safely  deduce  as  a  golden  rule  —  No  case  of 
vomiting  in  a  child  can  be  safely  despised  till  a  few  days  have  passed 
without  the  development  of  any  more  guiding  symptoms.  It  may,  how- 
ever, be  said  that  in  acute  gastric  conditions  food  will  be  at  once 
rejected,  while  in  all  other  forms  of  sickness  the  food  will  usually 
stay  down  for  some  little  time,  and  that  without  pain  or  discomfort. 

In  adults  we  may  draw  attention  specially  to  "  morning  vomiting  "  ; 
this,  when  repeated,  is  almost  confined  to  the  following  conditions : 
pregnancy,  alcohol  and  alcoholic  dyspepsia;  occasionally  the  vomiting 


V  SOME  SYMPTOMS  AND  AFFECTIONS  i6i 

of  uraemia  and  of  cerebral  tumour  assumes  this  type,  as  almost 
invariably  does  the  vomiting  which  is  brought  on  by  the  cough 
of  chronic  bronchitis.  Once  reminded  of  this  peculiarity  diagnosis 
is  not  difficult. 

COLIC 

Strictly  speaking,  the  terms  "  colic  "  and  "  colicky  pain  "  should  be 
reserved  for  intermittent  or  at  least  remittent  painful  sensations  in 
the  abdomen,  or  referred  to  the  abdominal  viscera  ;  but  I  wish  here, 
for  convenience'  sake,  to  use  the  expression  in  a  more  comprehen- 
sive sense  to  include  all  forms  of  severe  pain  referred  by  the  patient 
(either  by  voice,  or  gesture  in  those  unable  to  speak)  to  the  ab- 
dominal or  pelvic  region.  Pain  thus  referred  may  arise  from 
disease  of  any  structures  of  the  trunk  below  the  thorax,  for  none  of 
the  viscera  were  intended  for  organs  of  special  localising  sense, 
so  that  pain  arising  in  one  part  is  frequently  misreferred  to  another 
spot.  For  this  very  reason  the  differential  diagnosis  of  the  various 
causes  for  the  symptom  assumes  here  a  greater  importance  than 
in  any  other  region,  especially  as  the  treatment  for  one  cause 
of  the  pain  w^ould  be  absolutely  and  rapidly  fatal  if  another  cause 
were  at  work,  e.g.  perforation  of  stomach  z'.  a  gall-stone. 

The  causes,  then,  are  many  and  various.  They  may  be  divided 
most  simply  into  groups  : — 

CAUSES  OF  ABDOMINAL  PAIN 

Group  I. — Affectio7is  of  the  Peritoneum  arid  Alimentary  Canal  itself 

(a)  Irritating  contents  of  the  gut  causing  either  congestion  of 
mucous  membrane   or  painful  peristalsis,  or  more  likely 
both  together. 
Food  unsuitable  in  quantity  or  quality. 
Foreign  bodies  of  any  description. 
Drugs,  active  purgatives,  or  poisons. 
(d)  Ulceration  and  other  disease  of  the  walls  ;  simple  ulcer  or 
tubercle,  or  carcinoma,  etc.     {jV.B. — It  is  astounding  how 
frequently  such  diseases  exist  without  causing  any  pain 
directly  by  their  mere  presence.) 
{c)  Embolus    of  a  mesenteric    artery  I  have  known   to  cause 
intense  agonising  colic  with  other  symptoms  like  obstruc- 
tion. 

M 


1 62  DIFFERENTIAL  DIAGNOSIS  chap. 

{d)  Obstruction  and  strangulation  of  the  gut,  whether  acute  or 
chronic,  and  however  arising  (intussusception  bands, 
hernia,  twists,  etc.). 

((?)  Peritonitis,  acute  or  chronic,  local  or  general,  however  aris- 
ing, independently  or  through — 

(/)  Perforation  of  any  hollow  viscus,  or  rupture  of  a  solid  one. 

{g)  Some  blood  alterations  or  blood-carried  poisons  must  be 
inserted  here ;  of  these  lead  and  gout  are  the  only  two 
of  practical  importance. 

(^h)  Nervous  disturbance  of  gut  from  independent  disease  or 
functional  condition  of  cord  or  brain ;  e.g.  the  gastric 
crisis  of  tabes,  or  of  G.P.I.  ;  or  disease  of  the  supra- 
renals ;  or  abdominal  nerve  complexus  as  met  with  in 
Addison's  disease,  etc. 

Group  II. — Affections  of  Organs  in  Direct  Connection  with  the  Gut 

(a)  Liver : — 

Inflammation  or  abscess,  primary  or  arising  in  connection 
with  a  previous  painless  affection. 

Carcinoma  and  other  rapidly  increasing  growths. 

Gall-stones  when  trying  to  leave  the  gall-bladder. 

Rupture  (only  traumatic). 
(3)  Pancreas : — 

Acute  inflammation. 

Stone  in  the  duct  (very  rare,  and  practically  outside  the 
range  of  certain  diagnosis). 
(c)  Spleen : — 

Abscess. 

Enlargement,  especially  if  also  mobile  enough  for  difficulties 
to  occur  in  the  circulation  to  and  from  it. 

Embolus  (pain  rarely  very  severe). 

Group  III. — Affections  independent  of  the  Ali77ientary  Tract  and  its 

Connections 

(a)  Of  the  urinary  tract : — 

Stone  or  other  painful  kidney  trouble. 

Kinking  or  disease  of  ureter. 

Bladder  :  distension  or  rupture. 
{S)  Abscess  from  any  source ;  its   presence  or  its  rupture  may 

cause  acute  pain. 


V  SOME  SYMPTOMS  AND  AFFECTIONS  163 

(c)  Aneurysm  :   its  presence  or  rupture. 

(d)  Affections   of  the  bones  of  the  vertebral  column,  especially 

caries. 

Group  IV. — In  women  the  pelvic  reproductive  organ  must  be 
borne  in  mind  as  the  possible  primary  source  of  growths, 
abscesses,  peritonitis,  bladder  disturbance,  etc. 

In  dealing  practically  with  such  a  heterogeneous  collection  of 
causes  for  acute  abdominal  pain,  it  is  obvious  that  we  must  have 
some  guiding  principle  on  which  to  work ;  though  a  general,  and 
often  even  a  precise  and  exact,  diagnosis  is  by  no  means  so  difficult 
to  arrive  at  as  might  at  first  sight  appear.  The  simplest  method 
appears  to  me  to  take  events  in  the  chronological  order  in  which 
they  occur,  with  possible  or  probable  narrowing  of  the  field  with 
each.  On  a  message  being  received  to  see  a  patient  in  this  condi- 
tion, the  first  information  naturally  given  is,  roughly,  the  age  of  the 
patient,  baby,  child,  or  adult.  We  may  say  at  once  that  in  subjects 
under  puberty  direct  alimentary  disturbances  are  almost  alone 
to  be  thought  of — intestinal  obstruction  or  strangulation,  simple 
colic,  possibly  appendicular  trouble  or  peritonitis,  or  may  be  even  a 
renal  stone — but  such  cases  as  tabetic  crisis,  Addison's  disease, 
aneurysm,  gall-stone,  etc.,  may  be  at  once  excluded.  After  puberty 
no  such  general  rule  can  be  laid  down,  though  it  is  true  that  certain 
troubles,  e.g.  gall-stone  and  malignant  obstruction,  are  much  more 
frequent  in  stout  elderly  patients  than  are  others,  e.g.  intussuscep- 
tion or  perforating  acute  ulcer. 

The  next  step,  as  things  occur  in  practice,  is  to  inquire  of  the 
friends  as  to  the  previous  illnesses  of,  or  similar  attacks  experienced 
by,  the  patient,  and  also  as  to  symptoms  additional  to  the  pain  : — 

Is  this  the  first  attack  ? 

A.  If  not,  has  the  patient  previously — 

Been  jaundiced  ? 

Passed  gravel  ? 

Had  urinary  trouble  or  difficulty  ? 

Complained  of  anything  suggestive  of  G.P.I,  or  tabes? 

Suffered  from  marked  irregularity  of  bowels  ? 

Lost  much  flesh,  or  rapidly  emaciated  ? 

B.  If  it  is,  How  did  it  come  on  ?     Was  it — 

(a)  More  or  less  gradually  in  the  course  of  a  fairly  definite 


1 64  DIFFERENTIAL  DIAGNOSIS  chap. 

illness,  or  at  least  has  the  patient  been  complaining 

long? 

e.g.  Typhoid.  Gall-stones. 

Addison's  disease.     Gastric  ulcer.     Dyspepsia. 

Phthisis. 

Gout. 

or,  {B)  Suddenly,  in  the  midst  of  perfect  health  ? 
e.g.   Latent  gastric  ulcer  with  perforation. 
Hernia  or  other  strangulation  of  gut. 
Appendicular  trouble. 
Indigestible  meat,  poisons,  etc. 

The  answers  to  these  questions,  and  independent  statements  by 
friends,  will  very  probably  have  thrown  great  light  upon  the  case, 
excluding  certain  causes  almost  to  a  certainty,  and  bringing  others 
forward  into  equal  prominence  as  probabilities.  Any  symptoms 
additional  to  the  pain  will  also  very  likely  throw  great  light  in 
certain  diagnostic  directions.  Those  more  particularly  to  be  asked 
for  if  information  is  not  volunteered  are — 

Vomiting. 

Constipation  or  other  state  of  bowels,  such  as  straining  at  stool, 

or  diarrhoea. 
Strangury,  or  frequency  of  micturition,  or  other  obvious  urinary 

trouble. 
History  of  blow,  or  other  accident. 

After  gaining  as  much  information  as  possible  from  what  may 
be  called  external  sources,  the  next  step  is  to  visit  the  patient  and 
make  as  careful  an  examination,  verbal  and  physical,  as  circum- 
stances will  permit. 

We  will  now  for  a  moment  leave  diagnosis  itself,  to  consider 
the  object  we  have  to  gain  by  it,  viz.  correct  treatment  of  the 
condition. 

Treatment  of  acute  abdominal  pain  must  proceed  on  one  of 
four  lines : — 

A.  Absolutely  expectant,  except  for  the  outward  application  of 

hot  fomentations,  or  an  ice  bag; 

B.  A  hypodermic  injection  of  morphia,  or  inhalation  of  general 

anaesthetising  agents,  such  as  chloroform  or  ether ; 

C.  An  emetic  or  purge ; 

D.  Prompt  surgical  interference  :  manipulative  or  by  the  knife  ; 


V  SOME  SYMPTOMS  AND  AFFECTIONS  165 

and  it  is  primarily  the  object  of  diagnosis  to  determine  upon  which 
of  these  Unes  we  may  most  safely  proceed. 

The  last  is  out  of  all  proportion  the  most  important  from  every 
point  of  view,  so  we  will  first  investigate  the  symptoms  which  indi- 
cate that  a  condition  is  present  which  demands  this  Hne  of  treat- 
ment.    The  conditions  themselves  are  : — 

1.  Perforation  or  rupture  of  any  hollow  or  solid  viscus  (gut, 

bladder,  uterus,  liver,  etc.),  or  of  any  pathological 
tumour  in  the  widest  sense  of  the  word  (aneurysm, 
cyst,  abscess,  etc.). 

2.  External  strangulation  (strangulated   herniae   of  all  sorts 

palpable  externally),  or  internal  strangulation  of  a  viscus 
or  tumour  by  twist  of  its  pedicel,  or  by  band,  etc. 
(internal  herniae,  etc.). 

3.  Acute  general  peritonitis  of  unknown  origin  (as  well  as 

most  cases  of  known  definite  causation). 

4.  Acute  pancreatitis  and  embolus  of  a  mesenteric  artery, 

which  cause  symptoms  precisely  resembling  those  of 
strangulation  of  the  gut,  and  can  only  be  distinguished 
on  operation. 

5.  Distended  bladder. 

6.  Displacements  of  pregnant  or  pathological  uterus,  causing 

urgent  symptoms. 

Luckily  most  of  these  conditions  are,  even  in  their  earliest  stages, 
usually  associated  with  such  diagnostic  features  as  to  be  at  once 
recognisable  as  a  group  of  cases.     Thus  the — 

Pain. — Is  very  sudden  in  onset,  rapidly  becoming  agonising  in 
character,  may  be  continuous  or  intermittent,  and  in  many 
external  hernial  cases  so  correctly  localised  as  to  direct 
attention  at  once  to  the  seat  of  trouble. 

Aspect  of  the  Patient. — Is  frequently  distinctive,  with  ashen  pallid 
face,  and  eyes  deeply  sunk,  and  pinched  features ;  collapse 
very  profound,  with  cold  and  clammy  sweat. 

Pulse. — Is  small,  thready,  and  frequent. 

Tongue. — Is  very  dirty,  and  with  great  tendency  to  dryness. 

Vomiting.  —  Is  often  incessant,  most  distressing,  very  rarely 
indeed  quite  absent;  if  any  delay  has  occurred  may  be 
stercoraceous. 


i66  DIFFERENTIAL  DIAGNOSIS  chap. 

Constipatio7i.  —  Absolute  since  the  onset  of  pain ;  thus  dis- 
tinguishing such  cases  from  virulent  poisons,  in  which 
diarrhoea  is  present  with  vomiting. 

Abdomen. — Is  very  tender  to  touch  as  well  as  painful,  and  may 
be  already  distended  or  rapidly  becoming  so ;  evident 
laboured  waves  of  peristalsis  may  be  present  and  give  useful 
information. 

Urine. — May  be  much  diminished,  or  totally  suppressed  without 
strangury. 

Should  all  these  indications  be  present,  or  even  two  or  three  of 
them  in  well  marked  form  (especially  small,  thready  pulse,  dry 
tongue,  and  incessant  vomiting),  there  can  be  no  room  for  hesitation 
if  life  is  to  be  saved — piompt  surgical  measures  must  be  adopted, 
manipulative  or  by  cutting,  according  to  circumstances.  It  how- 
ever only  too  frequently  happens  that  the  symptoms  are  not  so 
well  marked  at  the  onset,  and  diagnosis  must  perforce  be  postponed 
for  an  hour  or  two.  The  only  safe  and  golden  rule  is  then  :  "  In 
any  case  presenting  the  above  features  in  doubtful  form,  but  where 
suspicion  is  in  the  slightest  degree  aroused,  no  morphia  must  be 
administered";  for  thereby  many  of  the  most  important  developments 
are  masked  or  prevented ;  but  the  patient  must  be  placed  under 
intelligent  observation  with  hot  or  cold  abdominal  applications,  and 
his  case  must  be  reinvestigated  in  an  hour  or  two,  by  which  time 
the  diagnosis  will  have  become  more  certain.  Measures  may  then 
be  taken  accordingly. 

A  distended  bladder,  though  possibly  a  cause  of  acute  abdominal 
pain,  ought  not  to  be  difficult  of  diagnosis ;  if  the  distension  is 
sufficient  to  cause  pain,  the  viscus  will  always  be  easy  to  feel  as  a 
centrally  placed  abdominal  tumour.  A  bladder  ruptured  through 
disease,  though  probably  causing  symptoms  belonging  to  (i) 
(where,  indeed,  it  has  been  placed),  will  have  invariably  been  pre- 
ceded by  a  long  history  of  urinary  trouble  and  difficulty,  and  will 
have  thus  been  diagnosed. 

The  pregnant  uterus  will  likewise  not  offer,  under  these  circum- 
stances, any  diagnostic  difficulty.  Cases  of  rupture  come  under 
(i),  and  the  blanched,  bloodless  aspect  of  the  collapsed  patient  will 
be  suggestive  in  a  woman  known  or  suspected  to  be  pregnant. 

Into  the  more  definite  diagnosis  of  these  cases  I  do  not  propose 
here  to  enter :  the  keenest  diagnostician  must  frequently  content 
himself  with  saying,  "  Laparotomy  is  urgently  indicated,"  leaving 
the  operation  to  disclose  the  exact  condition.     Thus,  acute  pancrea- 


V  SOME  SYMPTOMS  AND  AFFECTIONS  167 

titis  presents  all  the  features  of  acute  intestinal  strangulation^  and 
acute  perforative  peritonitis  is  often  identical  in  its  symptoms  with 
volvulus  or  internal  hernia. 


Abdominal  Cases  without  Marked  Collapse 

Collapse  developing  very  early  in  the  case  (almost  from  the 
instant  of  onset),  with  its  attendant  facies,  pulse,  etc.,  we  have 
hitherto  taken  as  the  guiding  principle  in  diagnosis.  We  have  now 
to  consider  those  cases  of  abdominal  pain  in  which  it  is  not  so 
marked,  may  be  even  absent,  at  any  rate  in  the  earlier  stages. 
Such  cases,  especially  if  on  examination  no  pathognomonic  sign 
is  present,  still  call  for  the  keenest  eye,  clearest  understanding, 
and  most  incessant  watchfulness,  that  at  the  earliest  moment  the 
cloven  hoof  betraying  serious  developments  may  be  detected — 
something  more  than  pain  written  in  the  face,  some  smallness 
and  frequency  of  pulse  out  of  proportion  to  the  expected;  a 
persistency  of  vomiting,  or  alteration  in  the  character  of  the 
vomited  matters — any  or  all  of  these  features  may  be  found  on  a 
second  visit. 

In  no  case  of  painful  abdominal  affection  can  it  be  said  that 
collapse  must  be  absent,  but  it  is,  at  any  rate  in  severe  shape,  an 
exceptional  feature  in  otherwise  fairly  healthy  people  (at  the  ex- 
tremes of  life  or  in  broken  down  subjects  great  caution  in  judgment 
is  necessary),  when  one  of  the  following  is  present,  causing  complaint 
of  abdominal  pain  : — 

Simple  colic,  from  improper  contents  of  gut,  or  due  to  lead, 
gout,  or  Addison's  disease,  or  nervous  troubles  ; 

Liver  diseases,    apart  from    a   possible    suppurative   peritonitis 
arising  from  it ; 

Chronic  obstruction  of  bowels  \ 

Typhlitis ; 

Aneur3^sm ; 

Caries  of  spine ; 

Retroperitoneal  growth ; 
and  we  shall  now  proceed  to  discuss  their  differential  diagnosis  on 
the    assumption    that   the    patient  is  capable   of  giving  intelligent 
answers    to    questions,  and    that   a    thorough    examination   of  the 
abdomen  is  allowable  and  allowed. 

On  approaching  the  patient  definite  jaundice,  if  present,  will  at 
once  attract  notice  {N.B. — by  artificial  light  this  is  very  easily  over- 


1 68  DIFFERENTIAL  DIAGNOSIS  chap. 

looked,  in  fact,  impossible  to  detect,  and  the  question  of  its  presence 
must  always  be  asked),  and  direct  attention  to  the  liver  as  in  some 
way  the  cause  of  the  trouble.  The  discovery  of  jaundice  would 
also  lead  to  questions  as  to  its  previous  occurrence,  if  such  had  not 
already  been  put.  The  pigmentation  of  Addison's  disease  would 
at  this  stage  possibly  attract  attention,  and  if  present  go  far  towards 
the  elucidation  of  the  diagnostic  problem. 

General  inquiries  to  estabhsh  points  left  doubtful  by  the  friends 
may  then  be  put  to  the  patient ;  their  scope  has  been  already 
indicated.  The  abdomen  must  then  be  exposed,  and  the  patient 
asked  to  point  out  the  seat  of  greatest  pain,  and  the  direction  (if 
any)  in  which  it  seems  to  travel ;  this  point  is  often  useful,  but  as 
already  noted,  too  much  stress  must  not  be  laid  upon  it,  owing  to 
the  vagaries  of  referred  pain. 

The  orderly  methodical  examination  of  the  abdomen  by  inspec- 
tion, palpation,  and  percussion,  and  even  by  the  stethoscope,  may  be 
proceeded  with,  and  if  there  is  still  a  doubt,  a  vaginal  or  rectal 
examination,  or  both  if  necessary,  must  be  made. 

This  examination  will  almost  for  a  certainty  have  revealed  any 
of  the  following  points  which  are  present : — 

1.  Whether  the  pain  is  greatly  increased  by  pressure,  or  some- 
what relieved  as  a  steady  pressure  becomes  firmer  and  deeper ;  the 
former  suggestive  of  peritonitis  or  serious  organic  disease,  the  latter 
of  simple  colic. 

2.  Hardness  or  increased  resistance  of  the  muscles,  either  locally 
or  generally,  suggestive  of  some  inflammatory  trouble  beneath  them. 

3.  Tumour  or  swelling  of  liver,  spleen,  kidney,  or  bladder,  or 
independently  existing  in  abdomen,  suggestive  of  its  being  the 
real  seat  and  possible  cause  of  the  pain,  or  indirectly  affording  an 
opportunity  for  obstruction  or  strangulation  of  the  gut. 

4.  Per  vaginam,  fixity,  or  swelHng  of  uterus,  or  other  palpable 
abnormal  condition  of  female  reproductive  organs  again  directly  or 
indirectly  causing  the  mischief. 

5.  Per  rectu77t^  ballooning,  or  the  peculiar  smell  of  carcinoma 
(not  easy  to  describe,  but  like  some  other  smells  once  experienced 
never  forgotten)  or  definite  stricture,  or  tumour  within  reach  of 
finger,  all  suggestive  of  carcinoma  or  other  serious  rectal  disease,  or 
intussusception  reaching  the  rectum. 

6.  In  cases  still  obscure  we  shall  have  tried  to  elicit  pain  on 
flexing  thigh  against  resistance,  suggestive  of  renal  or  appendicular 
or  psoas  mischief,  or  tenderness  on  tapping  or  jarring  spine,  sug- 
gestive of  caries  or  other  serious  bone  mischief. 


V  SOME  SYMPTOMS  AND  AFFECTIONS  169 

Founded  upon  these  and  similar  features,  we  may  epitomise  the 
principal  points  of  differential  diagnosis  in  such  cases  as  follows : — 

Differential   Diagnosis  of  Causes    of  Abdominal    Pain    not 

USUALLY    associated  WITH    MaRKED    CoLLAPSE,   OR    URGENTLY 

demanding  active  interference 

Colic^  Si7nple  or  Functional^  of  Intesti?te 

Probable  history  of  an  over-full,  indigestible,  or  unsuitable  meal ; 
pain  probably  relieved  or  not  made  worse  by  pressure ;  vomiting 
severe,  but  not  prolonged,  and  diarrhcea  probably  present,  or  soon 
sets  in. 

Lead  and  gout  must  be  thought  of  in  adults  as  a  possible  cause, 
and  a  blue  line  on  gums  or  tophi  looked  for,  and  inquiries  made  of 
occupation,  etc. 

Tabes  dorsalis  and  G.P.I.  must  also  be  remembered  in  this  con- 
nection, and  the  knee  jerks  and  pupils  investigated. 

After  all  is  said  and  done,  the  most  important  problem  is  here 
to  separate  these  cases  from  commencing  local  or  general  peri- 
tonitis, and  from  forms  of  intestinal  obstruction  which  begin  in- 
sidiously (overlooking  a  gall-stone  or  renal  calculus  is  less  serious, 
but  vide  below),  and  the  -vdtal  importance  of  the  subject  must  be  my 
excuse  for  repeating  and  bringing  into  closer  contrast  the  likenesses 
and  differences  of  the  two  conditions. 

Besides  the  mere  pain  itself,  then,  they  may  be  alike  in — 

1.  The  vague  localisation  of  the  pain. 

2.  The  suddenness  of  its  onset. 

3.  The  universal  tenderness  of  the  abdomen  on  light  pal- 

pation. 

4.  The  intensity  of  the  pain. 

But  they  more  frequently  and  essentially  differ  in — 

Functional  colic.  Obstruction  and  Peritonitis. 


Locality. 

Very  vague,  usually  epi- 

Not    unfrequently     cor- 

gastric or  umbilical. 

rectly  localised. 

Suddenness. 

Gradually    rising    to     a 

Most     commonly     abso- 

maximum, and  waning 

lutely      sudden,      and 

and  waxing. 

then    persistent    at    a 
high  pitch. 

Superficial  tender- 

Often     great,     in     fact. 

May    be    great,    but    is 

ness. 

greater      than      when 

never     greater     than 

170 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Collapse,  includ- 
ing sunken  eyes, 
small  pulse, 
dry  tongue, 
clammy  sweat, 
etc. 

Vomiting. 


Constipation. 


Diarrhoea. 


Abdominal  swell- 
ing or  tympan- 
ites. 


Muscular  rigidity. 


Functional  Colic. 

fairly  firm  pressure  is 
applied,  which  may 
completely  check  the 
pain. 
Rarely  present,  except  at 
extremes  of  age  and 
in  broken  -  down  sub- 
jects. 


Rare,  except  in  acute 
poisoning  by  drugs  or 
food,  and  then  never 
stercoraceous,  and  only 
excited  by  food. 

Not  common,  except  in 
lead  poisoning. 


Far  more  frequent  than 
constipation,  except  in 
lead  colic. 


Practically  do  not  occur, 
at  any  rate  early  in  the 
case. 


Easily  overcome,  if  pre- 
sent, by  gentle,  steady, 
persistent  pressure. 


Obstruction  and  Peritonitis. 

that    caused    by    firm 
pressure. 


Usually  comes  on  at 
once,  and  in  any  case 
develops  very  rapidly; 
only  in  the  rarest  of 
instances  is  it  quite 
absent. 

Very  common  indeed, 
usually  very  persist- 
ent, and  may  be  ster- 
coraceous, independ- 
ent of  food. 

Usually  complete  (even 
to  wind)  after  the 
onset  of  pain  ;  bowels 
may  have  been  open 
just  previously  or  pain 
may  come  on  during 
defsecation. 

Only  exists  in  the  shape 
of  tenesmus,  with  pass- 
ing of  mucus  and 
blood.  N.B. — In  sus- 
picious caseSj  when 
diarrhoea  is  complained 
ofy  examine  the  alleged 
motions. 

General  distension  fre- 
quent, and  forms  a 
very  suspicious  feature 
indeed.  May  arise 
very  early  in  the  case. 

May  be  quite  local,  but 
is  usually  present,  and 
cannot  be  overcome, 
any  effort  to  do  so 
causing  great  increase 
in  the  pain. 


In  the  remaining   conditions   causing  severe    abdominal    pain, 


SOME  SYMPTOMS  AND  AFFECTIONS 


171 


immediate  diagnosis  on  the  first  or  even  second  visit  is  of  less 
vital  consequence,  though  important  enough,  as  it  must  essentially 
be,  if  medicine  is  to  maintain  any  grounds  of  claim  to  rank  as  a 
science. 

Affections  of  the  Liver 


Simple  non-purulent 
inflammation  or 
congestion. 


Suppuration. 


Carcinoma. 


Gall-stones. 


Two  cases  have  recently  come  under  my  care  in 
which  I  believe  this  condition  was  present ; 
the  pain  was  localised  to  the  right  hypochon- 
driac and  epigastric  region,  and  both  were 
associated  with  a  distinctly  appreciable  liver 
edge,  which  was  very  tender  on  pressure  or 
manipulation ;  in  both  alcohol  was  much  in 
evidence,  and  both  subsided  in  a  few  days 
without  further  symptom. 

Probable  history  of  dysentery  or  tropical  resi- 
dence ;  pain  localised  correctly  in  liver ;  fre- 
quently a  swelling  to  be  made  out ;  a  hectic 
type  of  temperature,  and  especially  if  associated 
with  night  sweatings  is  very  suspicious. 

Easily  diagnosed  if  tumour  is  felt ;  if  no  tumour, 
then  rapidity  of  loss  of  flesh  is  most  important 
feature,  when  the  locality  of  pain,  and  age  of 
patient,  rouse  a  suspicion. 

Possibly  previous  history  of  jaundice ;  patient 
usually  stoutish  and  middle-aged  or  older ; 
distended  gall-bladder,  if  present,  almost  con- 
clusive. 


It  is  usually  assumed  that  gall-stones,  renal  calculus,  and  simple 
colic  are  very  likely  to  be  mistaken  for  one  another.  The  following 
table  shows  their  contrasts  and  Hkenesses : — 

Gall-stones,  renal  calculus,  simple  colic  may  be  alike  in — 


1.  Sudden  onset  of  pain. 

2.  Sudden  cessation  of  pain. 
,  3.  Indefinite  locality  of  it. 

4.  Severity  of  it. 


172 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


They  more  commonly  differ  in- 


Gall-stones. 

Renal  Calculus. 

Simple  Colic. 

5- 

Locality 

Usually   referred 

Usually  in  back. 

Usually   referred 

and — 

more  correctly 
than  the  others 
to     the     right 
hypo  c  h  on- 
drium. 

loin,  and  groin. 

to  umbilicus  or 
epigastrium. 

6. 

Direction 

Pain     fixed,      or 

Travels    down 

Fixed  in  umbili- 

of pain. 

seems  to  pass 

groin  to  testi- 

cus, or  travels 

upwards. 

cle,    which    is 
frequently    re- 
tracted. 

across  abdo- 
men. 

7. 

Character. 

Not  intermittent. 

More      intermit- 
tent than  gall- 
stone. 

Usually  is  actu- 
ally intermit- 
tent. 

8. 

Calculus 
found. 

In    faeces    if    at 

all. 

In  urine  if  at  all. 

None. 

Associated 

Jaundice ;    urine 

Strangury  or  fre- 

Urination not  in- 

symptoms, 

dark   coloured 

quent  micturi- 

terfered   with. 

if  any. 

perhaps;  other- 

tion ;   possibly 

except     possi- 

wise the  func- 

bloody urine  ; 

bly  quantity 

tion  not  inter- 

function pretty 

diminished     if 

fered    with  ; 

certainly  inter- 

much     vomit- 

vomiting   may 

fered    with; 

ing,    which    is 

occur  from  the 

vomiting     less 

more  probable 

pain    or    asso- 

likely than  with 

than     in     the 

ciated    gastric 

biliary  colic. 

other  two. 

disturbance. 

Previous    his- 

Of  jaundice  and 

Of  gravel  in  urine, 

Of    "bilious    at- 

tory. 

similar  attacks. 

or  other  patho- 
logical   condi- 
tion of  urine. 

tacks,"  if  any- 
thing, or  of 
dropped  wrist. 

Age. 

Middle  or  later. 

Any  age. 

Middle         and 

young    most 

likely. 

Chronic  Obstruction  of  Bowels. — Previous  history  of  notable 
irregularity  of  bowels  ;  rectal  examination  may  give  very 
important  information ;  possibly  a  tumour  in  known  line  of 
colon  (malignant  or  intussusception). 

Typhlitis. — Pain  usually  correctly  referred  to  right  iliac  fossa; 
dulness  on   percussion  and   great   tenderness,   especially   at 


SOME  SYMPTOMS  AND  AFFECTIONS 


173 


M'Burney's  point    If  definite  swelling  and  redness  diagnosis 

nearly  conclusive. 
Aneurysm. — Tumour    has   expansile   pulsation ;    pain   more    in 

back  and  worse  at  night ;  bruit  possibly  heard  over  tumour. 

Vessels  elsewhere  degenerate :  history  of  syphilis  and  hard 

work  and  alcohol  probably. 
Caries. — Pain  also  referred  to  back,  probably  worse  on  jarring 

heels  or  tapping  spine ;  this  or  aneurysm  may  cause  definite 

cord  symptoms. 

Retroperitoneal  Growth. — Only  guessed  at  by  excluding  other 
causes  for  pain  or  cord  symptoms.  Possibly  a  tumour  of 
irregular  outline  may  be  felt,  lying  deeply,  and  without 
expansile  pulsation. 


DIARRHCEA  AND  CONSTIPATION 


The  causes  of  these  conditions  or  symptoms  may  thus  be  tabu- 
lated : — 


I.   Contents  of  the  gut. 
Too  liquid. 


Too  solid. 

Too  irritating. 
Foreign  bodies. 


2.  Walls  of  the  gut. 

{a)    Ulcers  :     if  not 
too  deep  to  par- 
alyse. 
{b)  Growths. 


{c)  Inflammation. 


Clinical  Illustrations. 

Doubtful  if  this  condition  per  se  ever  causes 
diarrhoea,  possibly  excessive  drinking 
might  do  it ;  unduly  active  peristalsis  may 
thus  cause  it  by  preventing  absorption. 

Probably  unusual  sweating,  habitual  neglect 
of  the  bowels  ;  fever  thus  possibly  causes 
constipation  by  too  great  absorption  of 
water. 

Improper  fermentation,  unripe  fruit  or  other 
indigestible  material. 

Either  by  their  presence  cause  irritation  pos- 
sibly, or  by  their  size  cause  obstruction, 
e.g.  purgative  drugs,  or  gall-stones,  etc. 

Tubercular,  typhoid,  dysenteric,  and  simple. 


May  cause   irritation,  and  so  diarrhoea,  or 

paralysis,     and    so    cause    constipation ; 

sometimes  by  bulk  or  cicatrisation   may 

also  cause  obstruction. 

of  peritonitis  leads  to  paralysis,  the  most 


174 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


(d)  Altered  structure. 

(e)  Altered      circula- 

tion. 

(/)  Blood  conditions 
or  toxaemias, 
which  may  either 
cause  excessive 
peristalsis  or  ex- 
cretion into  gut, 
or  both,  or,  />er 
contra^  may  act 
in  the  reverse 
manner. 

(^g)  Reflex  nerve  in- 
fluence, again 
acting  either  on 
peristalsis  or 
secretion,  or  both. 

(h)  Pressure  from 
without  acting 
mechanically  or 
reflexly, 

(/)  Some  unexplained 
causes. 


Clinical  Illustrations. 

obstinate  form  of  obstruction ;  milder 
forms  of  this  may  by  irritation  cause 
diarrhoea,  as  in  some  cases  of  appendicular 
or  cascal  trouble. 

Lardaceous  disease,  leading  to  obstinate  diar- 
rhoea. 

Heart  disease,  cirrhosis  of  liver,  either  con- 
stipation or  diarrhoea. 

Bright's  disease  (urgemia)  ;  gouty  habit ; 
probably  some  of  the  diarrhoeas  of  zymotic 
cases,  critical  or  otherwise,  are  thus  caused. 
Lead  is  the  best  known  example  of  the 
opposite  condition,  viz.  constipation. 


Cord  diseases ;  mental  states,  as  fear,  anxiety, 
insanity,  etc.,  dentition  in  babies,  com- 
monly causing  diarrhoea,  but  not  unfre- 
quently  the  reverse  ;  and  here  possibly 
may  be  placed  the  too  solid  motions  of 
habitual  neglect. 

If  an  abdominal  tumour  presses  on  the  gut 
it  is  likely  to  cause  constipation,  but  some- 
times it  may  cause  diarrhoea  reflexly,  or 
by  direct  irritation. 

e.g.  To  what  shall  we  attribute  the  almost 
universal  constipation  of  the  early  days  of 
sea -air,  or  other  changes  of  climate  and 
temperature  ? 


The  majority  of  the  above  cases  offer  no  difficulty  in  diagnosis, 
for  the  constipation  or  diarrhoea  is  merely  a  concomitant  symptom 
of  some  obvious  disease  or  departure  from  the  ordinary  habits — 
dietetic,  physical,  or  general — of  the  individual ;  but  a  few  guiding 
rules  of  procedure  are  required  for  the  elucidation  of  those  cases  in 
which  the  diarrhoea  or  constipation  is  the  only  obvious  symptom 
from  which  the  patient  is  suffering,  or,  at  least,  of  which  he  complains. 

In  any  such  case  the  first  and  most  important  thing  to  ascertain 
is  the  precise  meaning  attached  by  the  patient  to  the  words  he  uses — 
ask  how  often  the  bowels  act,  whether  much  tenesmus  or  not,  and 


V  SOME  SYMPTOMS  AND  AFFECTIONS  175 

the  quantity  and  character  of  what  passes,  and  inspect  the  motions 
for  this  purpose  if  necessary.  A  case  recently  has  occurred  to  me 
in  which  the  patient  complained  of  an  obstinate  diarrhoea.  Some- 
what puzzled  by  my  ineffectual  efforts  at  drug  treatment,  I  was  led 
to  ask  him  to  save  everything  passed  for  twenty-four  hours ;  I  then 
found  all  the  motions  solid  and  natural,  and  further  inquiry  led  to 
the  conclusion  that  it  was  simply  a  case  of  a  gross  feeder  whose 
bowels  required  naturally  a  more  frequent  relief.  This  inquiry  and 
inspection  will  probably  result  in  the  discovery  of  any  of  the  follow- 
ing conditions  of  the  stools  : — 

Natural  in  Consiste?icy  and  Quantity. — As  in  the  above  case. 
If  motions  very  narrow  and  ribbon-Uke,  probably  a  stricture, 
organic  or  spasmodic  (of  sphincters),  is  present. 

Much  Fecule?it  Material.,  but  too  Watery^  Light ^  or  Dark. — If  light 
or  natural  colour,  suggestive  of  simple  irritation  of  upper 
bowel  by  unsuitable  food  j  if  dark  and  tarry,  strongly  sug- 
gestive of  hemorrhage  (^.^'.),  high  up. 

Masses  of  Undigested  Food  or  Curds  {in  Children),  so-called  Lien- 
tery. — Suggestive  primarily  of  unsuitable  or  too  free  feeding, 
e.g.  too  much  milk  in  typhoid ;  and  if  this  question  is  satis- 
factorily determined  in  the  negative,  then  suggestive  of 
undue  nervous  influences,  perhaps  best  treated  by  bromides 
or  ner\-ine  tonics. 

Pea-soupy  Stools. — Might  rouse  a  suspicion  of  insidious  typhoid, 
and  should  lead  to  the  use  of  the  thermometer. 

Scybalous  Knobs  or  very  hard  Fceces  ;  probably  with  much  Mucus. 
— Suggest  a  false  diarrhxjea,  due  to  undue  constipation ; 
hardening  of  the  fasces ;  a  most  important  class  of  cases, 
because  they  are  so  common. 

Pus^  or  Pus  a7id  Blood;  Mucus,  or  Blood  and  Mucus. — Rupture 
of  an  abscess  into  bowel.  Much  mucus  is  a  pathognomonic 
sign  of  colonic  trouble,  and  if  present  with  hardened  lumps 
almost  certainly  indicates  constipation,  either  simple  or  due 
to  organic  obstruction,  as  the  real  trouble ;  if  with  blood  it 
is  suggestive  of  dysentery,  malignant  or  other  stricture,  piles, 
fistula  in  ano,  etc. 

Me??ibra?20us  Masses  floating  in  Water. — Membranous  colitis  ;  in 
the  absence  of  an  acute  illness  rather  suggestive  of  malignant 
disease,  or  occasionally  chronic  obstruction  or  simple  con- 
stipation. 

The  anus  at  least,  and  better  also  the  rectum,  should  then  be 


176  DIFFERENTIAL  DIAGNOSIS  chap. 

inspected  and  examined  to  see  if  any  pathological  condition  is  there 
present  which  can  cause  diarrhoea,  or  at  least  explain  the  patient's 
complaint,  thus  : — 

Piles  or  Simple  Polypi. — May  explain  blood  and  mucus,  excessive 
straining  pain,  etc. 

Fistula. — By  its  discharge  may  have  given  a  false  impression  of 
diarrhoea,  as  well  as  altering  the  material  of  a  stool. 

Balloofiing. — If  well  marked  is  strongly  suggestive  of  a  stricture 
just  out  of  reach,  or  that  can  with  an  effort  be  just  touched. 

Stricture. — MaHgnant,  syphilitic,  etc.,  will  explain  either  diarrhoea 
or  constipation,  or  a  marked  alternation  of  the  two  con- 
ditions. 

Rectu7n  full  of  Hardened  Fceces. — A  very  common  thing  to  find 
in  complaints  of  either  diarrhoea  or  constipation.  It  must 
be  emptied,  and  then  a  fresh  examination  made,  as  the 
condition  may  be  a  simple  one,  or  it  may  be  merely  a  symp- 
tom of  some  serious  trouble  to  be  discovered  by  the  ex- 
amination of  the  empty  viscus. 

Uterine  a?td  Ovarian  Troubles. — In  women  a  rectal  examination 
is  often  required  as  well  as  vaginal ;  it  is  possible  for  almost 
any  organic  disease  or  pathological  position  of  the  genitory 
organs  to  cause  a  disturbance  of  defaecation. 

A  systematic  examination  of  the  abdomen,  which  may  precede 
or  follow  the  rectal  one,  may  very  likely  reveal  an  efficient  explana- 
tion of  the  trouble.  Almost  every  pathological  condition  of  the 
abdominal  viscera  may  cause  alteration  in  alvine  evacuation,  e.g. 
liver  diseases  {q.v.\  splenic  enlargements,  any  abdominal  tumour, 
dilated  stomach  {q.v.),  tubercular  peritonitis,  or  any  other  form  of 
peritonitis,  or  ascites,  etc. ;  as,  however,  most  if  not  all  of  them 
will  have  given  rise  to  complaints  other  than  of  diarrhoea  or  con- 
stipation, they  mil  not  here  be  further  considered. 

Should  the  history  and  examination  thus  far  have  left  matters 
still  in  doubt,  the  patient  must  next  be  thoroughly  overhauled  for 
evidence  of  some  general  disease,  or  a  local  one  not  situated  within 
the  abdominal  region,  which  may  be  associated  as  cause  with  the 
symptoms  under  consideration.  These  are  chiefly  phthisis,  lard- 
aceous  disease,  plumbism,  Bright's  disease,  typhoid,  leucoc3'thaemia, 
and  other  blood  dyscrasias  or  definite  disease  of  the  spinal  cord  or 
brain. 

These,  like  the  troubles  mentioned  in  the  preceding  paragraph, 
hardly  require  in  this  connection  any  further  mention.     The  chronic 


V  SOME  SYMPTOMS  AND  AFFECTIONS  177 

cachexia,  or  suppuration,  with  the  enlarged  spleen  and  urinary  con- 
dition of  lardaceous  disease ;  the  blue  line,  colic,  and  occupation 
of  plumbism  ;  the  temperature  of  typhoid ;  the  blood  of  leucocy- 
thaemia  and  ansemia ;  the  low  specific  gravity  aiid  diminished 
urine  of  approaching  uraemia  (the  diarrhoea  is  really  a  uraemic 
phenomenon) ;  these  are  all  sufficiently  distinctive ;  and  so  are  the 
physical  signs  in  the  chest  of  a  phthisical  patient ;  but  it  must  not 
be  forgotten  that  in  consumption  there  are  several  possible  sources 
for  the  diarrhoea  which  require  a  little  consideration,  owing  to  their 
importance ;  thus  : — 

Causes  of  Diarrhcea  in  Phthisis 

{a)  Accidental,  as  it  were,  due  to  food,  or  change  in  climate, 
etc.,  from  which  phthisis  confers  no  immunity.  This 
may  be  sharp  while  it  lasts,  but  is  quite  temporary, 
rapidly  ceasing  or  yielding  to  treatment.  Some  change  in 
residence  or  diet  will  probably  give  the  clue  to  its  origin. 

ib)  In  association  with  the  dyspepsia,  w^hich  is  such  a  trouble- 
some accompaniment  of  phthisis,  particularly  in  its  earlier 
stages.  In  fact,  when  lung  mischief  is  doubtful  but  sus- 
pected, this  dyspepsia  is  a  very  suspicious  piece  of  diag- 
nostic evidence. 

{c)  Due  to  tubercular  ulceration  of  intestine.  Usually  occurs 
in  later  stages,  when  the  lung  trouble  is  very  distinct. 
Associated  with  slight  colicky  pains,  and  very  intractable 
to  treatment,  though  often  ceasing  spontaneously.  The 
presence  of  the  ulceration  cannot  be  diagnosed  with 
certainty,  but  pain,  and  especially  tenderness  in  the  abdo- 
men, are  suggestive  when  in  combination  with  an  obstinate 
diarrhoea. 

{d)  Lardaceous  changes  supervening ;  painless  in  itself,  absolutely 
rebellious  to  treatment ;  associated  with  distinctive  signs  of 
lardaceous  trouble  already  mentioned  in  spleen  and  liver, 
and  possibly  kidney. 

{e)  That  of  exhaustion  in  the  very  last  stage  of  the  disease ;  the 
active  cause,  in  fact,  of  the  fatal  ending  in  many  cases  not 
apparently  due  to  either  {c)  or  {d). 

Ascites 

The  methods  to  be  adopted  to  determine  the  presence  of  excess 

of  fluid  in  the  peritoneal  cavity  are  so  distinctly  laid  down  in  all  the 

N 


178  DIFFERENTIAL  DIAGNOSIS  chap. 

text-books  that  I  do  not  propose  to  discuss  them  except  in  tabular 
form,  to  separate  ascites  from  cystic  formations  in  the  abdomen 
i^ide  p.  i8i). 

The  causes  of  ascites  recognised  at  the  bedside  belong  to  only 
two  categories,  or  perhaps  three,  if  we  include  chylous  ascites. 

A.  Irritation  of  the  membrane  itself — 

/Tubercle  \  Either  of   the    mem- 

^     )  Carcinoma  (secondary)  (       braneor  of  an  organ 

^  \  Sarcoma  (primary  or  second-  f      covered   by  it,   e.g. 
\      ary)  /       ovary,  etc. 

Inflammatory  affections  of  the  peritoneum  apart  from 
growths  rarely  cause  marked  effusion,  unless  in  conjunction 
with  severe  kidney  mischief. 

B.  Undue  pressure  of  blood  in  the  portal  system,  which  may 

arise  from — 

1.  Local  Causes  in  Abdomen^  practically  confined  to  the 

Liver  and  its  Fissures^  e.g.  cirrhosis  of  liver,  alco- 
holic or  otherwise ;  perihepatitis ;  glands  or 
growths  (including  a  gall-stone  very  rarely)  in  the 
transverse  fissure,  whether  primary  or  secondary. 

2.  Produced  by  a  Pathological  Condition  of  other  Organs — 
'Either    secondarily    through    the     right 

heart,  or  by  extension  of  growths  and 
inflammation  from  the  pleura  through 
the  diaphragm.  When  due  to  kidney 
trouble,  it  arises  probably  from  altera- 
tion in  composition  of  blood,  not  from 
pressure. 

C.  Undue  pressure  upon  the  receptaculum  chyli  or  the  thoracic 

duct,  leading  to  transudation  of  a  milky  fluid  into  the  peri- 
toneum-chyle. 

To  determine  to  which  of  these  primary  groups  a  given  case  of 
ascites  must  be  referred  is  usually  a  comparatively  easy  task ;  to 
further  differentiate  the  precise  individual  cause  at  work  is  more 
difficult,  and  often  impossible,  without  exploration. 

In  practice  one  usually  first  proceeds  to  exclude  Group  B  2. 
The  history  of  the  onset  of  the  swelling  of  abdomen  will  here  give 


Heart 

Lungs 
Kidneys 


V  SOME  SYMPTOMS  AND  AFFECTIONS  179 

us  very  important  information — whether,  that  is,  the  ascites  was 
the  first  complaint,  or  whether  the  patient  had  long  suffered  from 
other  troubles,  such  as  cough,  or  shortness  of  breath,  puffiness  of 
face  or  limbs,  etc.  A  careful  examination  of  the  thorax  and  of 
the  urine  will  then  speedily  give  us  either  a  negative  or  positive 
result.  If  the  thoracic  organs  and  the  urine  are  found  to  present 
no  morbid  features,  we  may  be  at  once  sure  that  some  local-abdo- 
minal cause  is  at  work.  Should  any  of  them,  on  the  other  hand,  be 
found  in  a  markedly  pathological  condition,  we  know  at  once  that  a 
powerful  accessory  factor  is  present  in  the  case,  whether  local  causes 
are  at  work  or  not.  The  indications  from  the  above  examination  of 
the  thoracic  organs  will  rarely  if  ever  be  of  doubtful  significance,  for 
ascites  does  not  arise  from  such  causes  alone  until  and  unless  they 
are  of  pronounced  severity. 

To  ascertain  the  exact  local  cause  at  work  it  is  certainly 
advisable,  and,  if  much  fluid  is  present,  often  necessary,  to  empty 
the  abdomen. 

In  my  opinion,  this  should  always  in  the  first  instance  be  done  by 
a  small  surgical  incision,  and  not  by  a  trocar,  however  small :  {a) 
it  is  more  scientific  ;  {b)  safer  for  the  patient ;  {c)  gives  more  informa- 
tion as  to  the  exact  condition  of  affairs ;  {d)  it  has  been  known  to 
cure  cases  otherwise  deemed  incurable  ;  {e)  it  allows  at  one  operation 
removal  of  a  removable  cause  should  such  be  found. 

The  character  of  the  fluid  (in  whatever  way  it  be  obtained)  will 
at  once  detect  chylous  ascites.  A  microscopic  examination  must 
be  made  for  this  purpose,  not  only  to  differentiate  fat  droplets  from 
pus  corpuscles,  but  also  for  the  further  intention  of  deciding  the 
possible  presence  of  cells  of  heterotopic  character.  (Physiological 
injections  into  animals  will,  if  necessary,  detect  tubercle.)  Should 
chyle  be  present,  we  know  at  once  that  we  have  to  deal  with  a 
growth,  either  malignant  or  glandular,  or  possibly  (very  rarely  indeed) 
with  a  blood  parasite — Bilharzia  or  Filaria. 

Should  the  fluid  prove  to  be  clear  or  purulent,  we  have  to  deal 
with  one  of  the  causes  in  Group  A  or  B  (i).  Purulent  peritonitis  is 
almost  invariably  associated  with  {a)  severe  kidney  disease,  which 
will  have  been  already  detected;  {b)  perforation  of  a  viscus,  the 
occurrence  of  which  will  have  been  only  too  obvious ;  or,  {c)  in 
women,  extension  from  vagina,  uterus,  or  Fallopian  tubes,  a  mode 
of  production  always  to  be  suspected  in  the  sex  if  no  other  cause  is 
ascertainable.  If  the  fluid  has  been  obtained  by  incision,  this  will 
by  itself  have  probably  completed  the  diagnosis,  but  if  circumstances 
should  have  prevented  exploration,  the  following  are  the  principal 


i8o  DIFFERENTIAL  DIAGNOSIS  chap. 

diagnostic  factors,  attention  to  which,  in  addition  to  what  has  been 
said  already,  will  usually  clear  up  the  case : — 

Tubercular  Peritonitis. — History  of  vague  attacks  of  colic  and 
irregularity  of  bowels.  Abdominal  walls  probably  feel  thick 
to  pleximeter  finger  or  examining  hand ;  increased  resistance. 
Irregular  masses,  with  equally  irregular  dulness,  may  be 
appreciated.  Patient  usually  young,  though  (even  old)  age 
does  not  exclude  tubercle. 

Carcinoma. — Physical  signs  almost  identical  with  tubercle  in  the 
small  nodular  form,  and  even  on  the  post-mortem  table  the 
two  may  very  closely  resemble  one  another.  More  com- 
monly the  primary  growth  is  obvious  as  a  tumour — ovarian, 
gastric,  renal,  etc. 

Sarco7na. — If  secondary,  indistinguishable  from  carcinoma  for 
clinical  purposes.  If  primary  (of  omentum)  a  tumour  will 
be  felt  giving  a  sensation  to  examining  hand  identical  with 
ballottement  of  pregnancy.  Under  thirty-five  this  cause 
may  be  almost  at  once  excluded. 

Acute  Ltflajnmation. — Recognised  by  the  great  pain  and  tender- 
ness on  palpation ;  board-like  muscles  {vide  purulent  effusion 
above). 

Cirrhosis  of  Liver, — Admitted  history  of  alcohol,  or  if  not  of 
alcohol  then  of  morning  vomiting ;  possibly  piles  or  hsema- 
temesis.  Liver  usually  enlarged,  but  surface  regular,  or  at 
least  without  large  bosses  of  carcinoma. 

N.B. — Youthful  age  does  not  exclude  this  cause,  unfor- 
tunately. 

May  be  a  history  of  syphilis,  which  points  either  to 
cirrhosis,  gumma  in  portal  fissure,  enlarged  glands,  or  peri- 
hepatitis. 

Perihepatitis. — To  me,  as  an  independent  affection  this  is 
unknown,  but  I  have  seen  it  in  connection  with  chronic 
peritonitis  of  tubercular  or  malignant  origin,  and  also  with 
syphilis  and  with  heart  disease.  It  is  to  be  thought  of  when 
in  a  case  of  morbus  cordis  ascites  is  the  prominent  back  pres- 
sure symptom,  but  I  do  not  believe  that  it  ever  arises  or 
causes  trouble  as  a  primary  and  separate  disease. 

Glands  and  Growths  in  Portal  Fissure. — If  they  cannot  be  felt, 
will  only  be  diagnosed  by  a  process  of  exclusion  of  other 
troubles ;  but  when  the  cause  of  ascites^  can  usually  be  felt  after 
withdrawal  of  the  fluid. 


SOME  SYMPTOMS  AND  AFFECTIONS 


i8i 


Inspection    of  ab- 
dojuen. 


Palpation. 


Percussion, 


Thrill. 


Other  means. 


Free  Ascitic  Fluid.        v. 

Symmetry  usually  main- 
tained ;  flanks  usually 
bulge  markedly. 

No  tumour  to  be  felt,  or 
if  so  it  is  a  hard,  solid 
mass. 


Dulness,  particularly  in 
the  flanks  with  patient 
on  back,  possibly  only 
here  appreciable,  and 
definitely  shifts  by 
imperceptible  move- 
ment as  the  patient 
shifts  his  position. 


Cystic  Tumours,  or  Encysted 
Fluid  of  Ordinary  Origin. 

Usually  some  definite 
asymmetry  to  be  per- 
ceived ;  flanks  do  not 
bulge  particularly. 

Tumour  or  tumours  to  be 
distinctly  appreciated  ; 
possible  mobile,  and 
feel  cystic  and  fluctuat- 
ing. 

Dulness  usually  only 
appreciable  over  the 
tumour,  not  specially 
in  flanks  ;  if  it  shifts 
with  position  of  patient 
there  is  a  perceptible 
movement  of  some- 
thing inside  the  ab- 
domen, detectable  by 
palpation  also. 

Usually  not  obtainable  at 
all ;  if  it  is  so,  it  wdll 
only  be  in  a  limited 
area  through  the  body 
of  the  cyst,  not  through 
the  whole  abdomen. 

Bimanual  in  a  female 
shows  movements  of 
uterus  with  ovarian 
cyst ;  other  cystic  for- 
mations may  be  felt 
definitely  as  such,  of 
limited  extent  or  mobi- 
lity, or  both.  In  ovar- 
ian cyst  menstrual 
irregularities  may  also 
help  us. 

The  only  case  which  is  likely  to  cause  much  trouble  is  that  of  a 
large,  thin-walled  ovarian  cyst,  which  has  practically  filled  the  whole 
abdomen.  Here  even  a  careful  attention  to  the  above  points  may 
still  leave  us  in  doubt.  The  history  of  menstrual  irregularities,  and 
of  a  previous  asymmetry,  together  with  an  absence  of  all  presumable 


Frequently    to    be 
tected     through 
whole  abdomen. 


de- 
the 


In  females  bimanual 
examination  gives  no 
very  distinctive  infor- 
mation. 


1 82  DIFFERENTIAL  DIAGNOSIS  chap. 

causes  of  ascites,  will  probable  put  us  right ;  such  cases  are  nowa- 
days very  rare,  and,  of  course,  they  can  only  occur  in  the  female  sex. 
Very  great  obesity  of  the  abdominal  wall  is  a  great  obstacle  to  phy- 
sical examination,  and  such  a  case  demands  extra  care,  with  which 
difficulties  may  vanish,  but  frequently  only  an  examination  under  a 
general  anaesthetic  will  clear  up  a  doubtful  abdominal  case. 

Simple  Dyspepsia  v.  Gastric  Ulcer 

Even  in  an  elementary  work  dealing  with  diagnosis  it  seems 
impossible  to  omit  all  reference  to  this  subject,  for  the  cases  are 
so  common  in  which  we  desire  to  have  guidance,  and  yet  the 
definite  separation  of  the  two  conditions — perhaps  it  would  be 
more  correct  to  say  the  exclusion  of  ulcer — is  so  extraordinarily 
difficult,  that  I  feel  it  is  much  easier  to  criticise  the  criteria 
mentioned  in  text-books  than  to  offer  any  distinction  of  my  own. 

If  we  take  a  number  of  cases  of  gastric  ulcer,  either  proved  such 
by  autopsy  or  diagnosed  as  such  during  life,  we  find  the  following 
points  more  or  less  marked  : — 

1.  The  subjects  will  roughly  divide  themselves  into  two  groups : 
{a)  those  whose  ages  range  from  seventeen  to  thirty ;  (b)  those  from 
forty  onwards.  Group  («)  will  be  almost  entirely  composed  of  the 
female  sex,  and  the  majority  will  have  suffered  from  ansemia,  and 
they  will  not  have  wasted.  Group  {b)  will  be  composed  of  either 
sex  indifferently :  anaemia — except  for  hsematemesis — will  not  have 
been  marked,  but  loss  of  flesh  will  commonly  have  appeared. 

2.  Severe  pain  will  have  been  a  prominent  feature  in  the  history 
of  the  illness,  and  this  pain  will  have  frequently  displayed  the 
following  peculiarities  : — 

{a)  Caused  only  by  taking  of  food. 

\b)  Appeared  some  little  time  after  the  ingestion  of  food,  not 

at  once, 
(c)  Locahsed  to  a  limited  area,  usually  in   the  epigastric 

angle. 
{d)  Increased  by  pressure  on  the  spot,  and  often  only  then 

apparent. 
{e)  ReHeved  almost  immediately  by  vomiting  when  this  has 

occurred. 

3.  Vomiting  is  also  likely  to  have  been  frequent,  with  chief 
characteristics  : — 

(a)  It  occurred  rather  late  after  food. 


V  SOME  SYMPTOMS  AND  AFFECTIONS  183 

{b)  It  relieved  the  pain  almost  at  once. 

{c)   It  has  been  actual  blood  or  blood-tinged  at  least  once. 

4.  In  the  cases  fatal  from  ulcer  there  will  almost  invariably  have 
been,  in  addition  to  the  above : — 

(a)  Perforation  with  acute  peritonitis ;  or 

(b)  Very  severe  haematemesis ;  or  at  least 

{c)  Such  constant  severe  pain  and  vomiting  as  to  have  led 
to  death  by  exhaustion — this  last  mode  of  death  is 
commoner  in  the  group  of  older  patients. 

Hence  with  regard  to  diagnosis  it  is  very  easy  to  say  that  an 
ulcer  is  present  when  the  above  symptoms  occur  in  typical  severity. 
It  is  the  converse  of  this  proposition,  viz.  to  exclude  an  ulcer  when 
gastric  symptoms  are  slight,  that  offers  such  enormous  difficulties ; 
in  fact,  there  can  be  no  hesitation  in  saying  that  it  is  impossible  by 
cli7iical  methods  alone  to  prove  this  negative.  Will  the  Rontgen  rays 
here  again  help  us  ? 

It  is  being  constantly  proved  in  cases  that  are  operated  upon 
for  perforation,  less  commonly  in  ulcers  found  on  autopsy,  that  pain 
may  be — 

{a)  So  slight  as  to  be  practically  unnoticed. 

{b)  Relieved  by  taking  food. 

{c)   Generally  diffused  and  not  localised. 

id)  Unrelieved,  or  only  very  gradually  so  by  vomiting. 

That  vomiting  may  be — 

{a)  Absent  altogether. 

{b)  Not  bloody  nor  blood-stained. 
In  fact,  that  in  certain  cases  every  one  of  the  guiding  indications 
may  have  been  absent,  or  what  is  perhaps  worse,  may  have  been 
absolutely  contra  -  indicative.  These  exceptional  cases  are  far 
more  common  in  the  group  of  young  subjects ;  in  the  older  group 
the  features  are  more  constant,  though  not  even  there  entirely 
without  exceptions. 

Dr.  S.  Fenwick  has  adopted,  if  not  invented,  a  simple  method 
of  attempting  to  solve  the  diagnosis  by  getting  the  patient  to 
swallow  about  a  drachm  of  common  salt  in  a  tumbler  of  water  when 
the  stomach  is  empty ;  should  an  ulcer  be  present,  the  salt  coming 
in  contact  with  a  raw  surface  will  excite  a  lively  attack  of  pain ;  if 
ulcer  be  not  present,  pain  is  not  likely  to  be  caused  by  the  simple 
procedure.  The  same  plan  may  be  adopted  to  determine  whether 
an  ulcer,  which  has  been  diagnosed  as  present,  has  healed. 


1 84  DIFFERENTIAL  DIAGNOSIS  chap,  v 

Apart  from  this  clinical  manceuvre  we  can,  I  think,  only  lay 
down  the  following  rules  : — 

1.  Never  to  think  too  lightly  of  an  attack  of  dyspepsia  in  a 
young  woman,  especially  if  she  be  anaemic  as  well. 

2.  Whenever  it  is  possible,  even  at  some  inconvenience  to  the 
patient,  to  insist  on  a  soft  diet  and  a  few  days'  rest  in  bed  in  all 
cases  of  dyspepsia  which  have  not  arisen  from  a  fairly  definite 
cause. 

3.  A  persistent-local  (epigastric  usually)  pain  in  an  older  patient 
must  similarly  put  us  on  our  guard,  to  insist  upon  treatment  appro- 
priate to  ulceration. 

By  attention  to  these  rules  we  may  cause  some  trouble  to 
ourselves  and  our  patients,  but  we  shall  at  least  have  the  satis- 
faction of  having  avoided  anything  likely  to  make  matters  worse. 


CHAPTER   VI 

DISEASES    OF    THE    URINARY    ORGANS 

One  of  the  most  striking  facts  about  kidney  troubles  is  the  fre- 
quency with  which  they  occur  without  local  symptoms.  In  acute 
nephritis  it  is  true  that  aching  pain  in  the  loin  is  frequently  present, 
and  new  growths  of  the  kidney,  including  stone  under  that  head,  are 
usually  associated  at  some  period  of  their  growth  with  more  or  less 
severe  local  pain  :  but  chronic  Bright's  disease,  lardaceous  degenera- 
tion of  the  kidney,  and,  in  fact,  the  majority  of  those  cases  in  which 
the  most  serious  degeneration  and  disintegration  of  the  kidney 
structure  are  present,  only  betray  themselves  by  general  symptoms 
due  to  imperfect  depuration  of  the  blood,  and  by  alterations  in  the 
urine  of  such  a  character,  or  so  insidious  in  onset,  that  they  may 
not  have  attracted  the  attention  of  the  patient. 

For  a  discussion  of  the  general  symptoms  refer  to  the  heading 
Uraemia.  The  alterations  in  the  urine  are  sometimes  sufficiently 
obtrusive  to  be  called  symptoms,  sometimes  so  insidious  that  they 
must  be  relegated  to  the  class  of  physical  signs,  but  in  either 
instance  they  are  so  exceedingly  important  that  they  must  be  rather 
fully  discussed  for  diagnostic  purposes. 

Before  we  can  appreciate  or  estimate  pathological  changes  in  the 
urine  we  ought  to  have  a  satisfactory  general  idea  of  the  quantity 
and  quality  of  the  healthy  excretion,  and  also  of  its  physiological  or 
healthy  variations — a  subject,  which  long  experience  of  students  has 
taught  me,  is  dreadfully  neglected,  and  forgotten  as  soon  as  the 
examination  in  physiology  is  passed. 

Normal  Urine 

Should  possess  the  following  characteristics : — 

Quantity.  From  forty  to  fifty  ounces  in  the  adult. 

Appearance.  Clear  and  bright. 


1 86  DIFFERENTIAL  DIAGNOSIS  chap. 

Colour.  Amber  to  sherry,  light  or  dark. 

Reaction.  Acid. 

Sp.  gravity.  1015  to  1025. 

It  should,  in  an  adult,  be  passed  about  four  or  five  times  in  the  twenty- 
four  hours,  and  should  on  analysis  show  about  2  per  cent  of  urea. 

The  colour  is  due  to  various  urinary  pigments,  ultimately,  no 
doubt,  derived  from  bile  pigments  and  from  haemoglobin. 

The  reaction  is  due  to  the  presence  in  fairly  large  quantities  of  the 
acid  phosphate  of  sodium  NaHgPO^  {and  probably  of  the  analogous 
potassiuin  salt  also  in  smaller  quantities^  It  is  truly  wonderful  how 
this  simple,  well-established  fact  is  forgotten  by  students,  who  will 
persist  in  ascribing  the  acidity  to  uric  and  hippuric  acids,  regardless 
of  the  feeble  acidity  of  these  bodies,  and  their  insignificance  in 
quantity. 

Variations  in  Health 

In  health  the  following  are  the  chief  factors  influencing  the 
urine,  and  a  brief  epitome  of  how  and  why. 

I.  Exercise. — Physical  work  must  undoubtedly — by  mere  wear 
and  tear  of  fixed  tissues  as  well  as  by  quickening  circulation,  and 
therefore  oxidation  of  more  floating  capital — have  a  tendency  to 
throw  more  waste  products  into  the  blood.  These  waste  materials 
are  the  ultimate  oxidation  products  of  organic  food  stuff's,  HgO, 
CO2,  and  urea  or  uric  acid  (as  urates) ;  the  HgO  and  COg  pass  off 
in  large  measure  through  the  lungs  by  increased  respiratory  move- 
ment, and  through  the  skin  with  the  sweat,  which  is  also  markedly 
increased  by  exercise ;  hence  there  follows  as  a  natural  deduction, 
just  what  is  seen  in  actual  practice,  viz.  that  with  exercise  the  urine 
shall  as  a  rule  be  lessened  in  quantity,  but  increased  in  specific 
gravity,  by  a  higher  proportion  of  nitrogenous  waste  material  and 
inorganic  salts. 

At  first  this  nitrogenous  waste  takes  the  form  of  uric  acid,  so 
that  a  copious  deposit  of  urates  and  biurates  is  the  familiar  result 
of  a  hard  day's  work  in  one  who  is  unaccustomed  to  physical 
labour.  As  uric  acid  is  a  less  oxidised  product  than  urea,  i.e. 
contains  a  smaller  proportion  of  oxygen,  it  is  probable  that  this 
deposit  is  due  in  some  way  to  an  inefficient  supply  of  oxygen  to 
burn  up  the  increased  waste  suddenly  produced.  When  the  body 
has  had  time  to  accommodate  itself  to  the  circumstances,  the  more 
usual  metabolism  of  nitrogenous  waste  into  urea  again  comes  to  the 
fore. 


VI  DISEASES  OF  THE  URINARY  ORGANS  187 

2.  Food. — The  ingestion  of  food  influences  the  urine  in  two 
ways : — 

A.  Directly :  by  the  simple  excretion  of  excess  of  water  taken 
in — the  student  is  apt  to  forget  that  the  so-called  solids  of  the  food 
(^7)  contain  a  large  proportion  of  free  water,  {b)  produce  much  water 
by  their  oxidation,  so  that  it  is  not  only  the  drink  alone  of  the  food, 
but  the  solids  also  that  produce  this  excess. 

B.  Indirectly  :  during  gastric  digestion  a  quantity  of  HCl  is 
required,  the  manufacture  of  which  sets  free  a  corresponding 
quantity  of  sodium  in  the  blood,  with  the  result  that  the  phosphate 
of  sodium  in  the  urine  is  more  likely  to  become  NagHPO^  or  even 
NagPO^  rather  than  NaH2P0^. 

By  both  these  processes,  then,  the  quantity,  the  specific  gravity, 
and  the  acidity  of  the  urine  are  likely  to  be  influenced — the  first  in- 
creased, and  the  last  two  diminished ;  the  acidity  to  such  a  degree 
that  it  is  quite  within  physiological  limits  to  find  the  urine  neutral 
or  even  alkaline  after  a  full  meal. 

3.  Weather, — This  simply  has  reference  to  the  temperature 
to  which  the  skin  is  exposed  when  no  compensating  influences 
— such  as  exercise — are  at  work  on  the  circulation  through  it. 
Cold  causes  the  skin  to  contract,  and  diminishes  consequently 
its  circulation  and  excretion  of  sweat,  \\4th  the  result  that  the 
amount  of  urine  passed  is  increased  \  external  heat  will  have  the 
contrary  effect. 

4.  Mental  Conditions.,  such  as  fear,  certain  hysterical  states  on 
the  borderland  of  health,  and  especially  doubt  as  to  opportunities 
for  voluntary  micturition,  undoubtedly  have  an  influence  on  the 
secretion  of  urine  \  but  their  exact  mechanism  is  obscure,  and  we 
can  only  record  the  fact. 

Thus  we  see  that — 

V^^    yj      J  ]y[ay   all    be    profoundly  altered    by  exercise,   food, 

P-  5  _•)      "j      weather,  and  mental  conditions. 
Reaction,    \  ' 

We  will  now  proceed  to  discuss  from  a  diagnostic  point  of  view 
the  variations  in  urine  due  to  disease. 


i88 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Variations  in  Disease 
Increased  Frequency  of  Micturition 


May  to  due  to — 
Acute    inflamma- 
tion or  irritation 
of  kidney. 
Stone,    or    other 
growths   of  kid- 
ney, with  colic. 
Cystitis    and 
bladder  calculus. 


4.   Prostatic  troubles. 


5.   Polyuria. 


Chief  diagnostic  points. 

Very  small  quantities  at  a  time,  total  quantity 
much  diminished,  probably  blood  in  it ;  stran- 
gury not  infrequent. 

Also  like  acute  inflammation,  but  with  severe  pain 
(renal  colic,  ^.2/.)  probably  running  down  into 
groin. 

Total  quantity  probably  about  normal,  possibly 
alkaline  and  ammoniacal,  certainly  much  mucus 
deposit ;  probably  pain  in  bladder  or  perineum, 
which  may  only  be  at  end  of  act,  and  often 
referred  to  the  glans  penis. 

If  acute  the  act  is  itself  very  painful ;  if  chronic 
the  increased  frequency  of  micturition  is  chiefly 
at  night,  with  possibly  some  difficulty  in  starting 
the  act  during  the  day,  and  the  catheter 
(possibly  passed  with  difficulty)  shows  residual 
urine  ;  total  quantity  normal  or  greater  than 
usual. 

Vide  next  section ;  total  quantity  much  in- 
creased. 


Acute  congestion 
or  inflammation, 
if  primary. 

If  on  the  top  of 

old  mischief. 
Large  white  kid- 
ney. 

Blocking  of  ure- 
ter. 

Retention,    heart 

disease,  and  gen- 
eral circulatory 
disturbances. 


Total  Quantity 
Is  Di?ninisked  in 

Frequent    micturition ;      strangury ;     smoky     or 

definitely  bloody    urine ;  albumen   and   casts  ; 

possible  history  of  turpentine  or  copaiba,  etc., 

administration. 
The   same   features,  but  with  history  of  previous 

increased  quantity. 
Vide  section  on  L.W.K.     Urine  nearly  solid  with 

albumen  ;  patient  very  anaemic. 
If  of  both,  total  suppression  {q-v.)  ;  if  one  only, 

such  urine  as  escapes  possibly  normal;  probably 

severe  pain  in  groin  and  loin. 
Vide  Suppression  v.  Retention,  p.  216.     Moderate 

quantity     of    albumen ;     history    of    gradual 

di7ninutio7i  in  quantity  of  urine,  and  presence 

of  other  signs  of  heart   disease  or  circulatory 

disturbances. 


VI 


DISEASES  OF  THE  URINARY  ORGx\NS 


189 


Is  Increased  in 


/Cirrhotic  kidney. 


Consecutive       neph- 
ritis. 

Lardaceous  kidney. 


o  ^ 
u 

< 


^ 


o 
U 


1) 

c 

o 


f^ 


/ 


Hydronephrosis. 


Diabetes  insipidus. 


Diabetes  mellitus. 


Hysteria,  after  rigors 
of  malaria,  occa- 
sionally after 
crisis  of  acute 
disease. 


Low  specific  gravity,  little  albumen,  patient 
probably  over  forty-five  years  of  age  ;  few 
if  any  casts. 

Probably  considerable  number  of  casts ; 
fair  quantity  (up  to  one  quarter)  albumen, 
and  history  of  acute  kidney  trouble. 

Probably  also  enlarged  spleen  and  liver, 
and  known  cause  of  lardaceous  degenera- 
tion present  ;  albumen  considerable,  casts 
may  or  may  not  be  numerous,  and 
possibly  show  lardaceous  microscopic  re- 
action. 

Increased  quantity  only  at  irregular  intervals, 
and  urine  quite  likely  without  much  change 
from  normal  ;  abdominal  tumour  in  renal 
region  often  detectable. 

Quantity  enormous,  up  to  300  or  400  ozs.  ; 
specific  gravity  very  low  ;  absence  of  albu- 
men or  other  pathological  constituent. 

Specific  gravity  usually  above  1025,  but^  N.B. 
— sugar  may  he  present  in  U'ri7ie  of  specific 
gravity  below  1020;  presence  of  sugar; 
urine  of  peculiar  appearance  and  general 
symptoms  of  diabetes. 

Urine  offers  no  special  peculiarities ;  the 
polyuria  is  quite  temporar}',  and  the 
attendant  circumstances  are  quite  sufficient 
for  diagnosis. 


Colour 


Of  pathological  variations  in  colour  due  to  changes  in  the 
urinary  pigments  very  little  is  known,  and  still  less  use  can  be 
made  for  clinical  purposes  of  the  knowledge  we  do  possess  (perhaps 
with  the  exceptions  of  melanin  and  indican) ;  but  the  follow- 
ing substances  when  present  will  produce  evident  colour  variations 
from  the  ordinary,  and  these  variations  form  the  first  preliminary  or 
simple  test  for  the  respective  substances,  and  should  therefore  be 
remembered : — 


190 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Bile  pigments. 


Blood. 

Chyle. 

Carbolic  acid. 

Rhubarb. 

Santonin. 
HcB7tiatoxylin. 

Iodides  and  bromides. 

Methylene  blue  {occa- 
sionally given  for 
rheumatoid  -  arth- 
ritis'). 


Urine  a  yellowish  green  tinge  in  thin  layers, 
almost  black  in  thicker  ones  ;  if  shaken  the 
froth  possesses  a  beautiful  yellow  colour.  This 
yellowness  of  the  froth  is  pathognomonic  of  bile 
in  urine  (?  rhubarb  or  santonin). 

Urine  either  of  a  smoky  tinge  and  not  clear,  or 
possesses  the  red  colour  of  blood  more  or  less 
marked. 

Urine  distinctly  milky  throughout,  and  often  co- 
agulates into  a  soft  jelly. 

Urine  of  a  green  colour,  looking  almost  black  in 
thick  layers. 

Brownish  yellow  colour,  becoming  red  on  adding 
alkali,  disappearing  with  an  acid. 

Bright  yellow ;  disappears  with  free  acid. 

Reddish,  also  disappears  with  free  acid,  thus 
differing  from  red  colour  due  to  blood  ;  vide 
Hsematuria. 

Dark  colour  appears  on  adding  nitric  acid,  due 
to  setting  free  of  iodine  or  bromine. 

Urine  of  a  bright  blue  colour.  I  have  recently  seen 
a  case  of  eosin  in  the  urine  mistaken  for  blood 
— it  arose  from  eating  sweets  coloured  with 
eosin. 

Specific  Gravity 


Apart  from  the  knowledge  of  the  total  quantity  passed  in  twenty- 
four  hours,  variations  in  specific  gravity  have  very  little  positive  patho- 
logical significance.  A  high  specific  gravity  (over  1027)  should, 
however,  at  once  rouse  a  suspicion  of  glycosuria  i^q.v.\  while  a  low 
one  (under  1015)  should  immediately  start  inquiry  into  the  total 
quantity  passed,  etc.,  leading  in  the  direction  of  suspected  cirrhotic 
kidney,  unless  other  obvious  explanation  be  at  hand. 

Constituents  of  Urine  not  usually  found  in  Health, 

ANJ)    essentially    PATHOLOGICAL 

By  their  presence.         Blood,  pus,   casts,   sugar,    albumen,  chyle,  phos- 
phate of  lime  if  in  quantity,  bile. 
Or  by  excess.  Urates,  mucus. 

Or  by  altered  condi-     Triple  phosphates,  ammonia, 
tions  of  urine. 

For  convenience  of  discussion,  and  because  of  its  practical 
utility  in  urine  analysis,  we  may  divide  these  constituents  into  those 


VI  DISEASES  OF  THE  URINARY  ORGANS  191 

which  form,  or  are  chiefly  found  in  association  with,  a  deposit  of 
some  sort,  and  those  which  still  leave  the  urine  quite  clear  notwith- 
standing their  presence,  thus  : — 

Forming,  or  chiefly  found  in,  a  Deposit.  Leaving  the  Urine  clear. 


Phosphates  of  lime. 

Sugar. 

,,          triple. 

Albumen. 

Urates  and  uric  acid. 

Blood.    [If    in    quantity 

Oxalates. 

Chyle.    4      usually  makes 

Mucus. 

Bile.       [     urine  opaque. 

Pus. 

Casts. 

Blood  staining  a  precipitate. 

It  is  obvious  that  there  are  two  questions  requiring  answers  in 
connection  with  these  abnormal  constituents — 

(i)  By  what  tests  shall  we  recognise  them  ? 
(2)  What  clinical  diagnostic  use  can  we  make  of  the  information 
thus  acquired  ? 

To  the  first  of  these  questions  I  propose  to  give  merely  an 
outline  of  a  reply;  for  details  of  manipulation  special  manuals 
must  be  consulted,  as  I  am  chiefly  concerned  with  clinical  and  not 

scientific  questions. 

Tests  for  the  Nature  of  an  Abnormal  Constituent 

OF  THE  Urine 

There  are  three  methods  to  be  adopted  in  testing  urine,  all 
of  which  should  be  employed  in  turn  as  corroborating  one  another  : 
(i)  ordinary  physical  examination  by  the  eye  and  nose;  (2)  chemi- 
cal experiments;  (3)  microscopical  investigation;  if  very  great 
accuracy  is  demanded,  the  spectroscope  may  be  used  to  detect 
blood  and  bile. 

Smell 

Of  ammonia.  Indicates  decomposition,  and  so  far  gives  a  clue 

to  the  improbability  of  a  deposit  being  urates, 
but  suggests  pus  or  triple  phosphates. 

Of  violets.  That  the  patient  has  been  taking  turpentine. 

These  are  the  only  two  indications  that  smell  is  likely  to  give 
one,  but  asparagus  and  possibly  other  articles  of  diet  do  alter  the 


192 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


natural  smell   of  healthy  urine,   though  the  fact  is   not   of  much 
clinical  value. 

Appearance  to  Naked  Eye  of  Urinary  Deposit  or  Urine 


Phosphate  of  lime?- 

Triple  phosphates? 
Urates. 

Uric  acid. 

Oxalates. 
Mucus. 


Pus. 


Blood. 
Sugar. 

Casts  and  Albumen. 
Bile. 


White,  more  or  less  granular  deposit  ;  some- 
times in  large  amount  (  =  phosphatic  diabetes), 
and  may  be  hummocky  from  intermixture  of 
mucus. 

Only  recognised  accurately  by  microscope  in  a 
deposit ;  urine  ammoniacal. 

Usually  coloured  pink  or  red  ;  if  white  they  may 
be  distinguished  from  phosphates  by  the  fact 
that  they  usually  adhere  to  the  side  of  the 
vessel  at  the  top  of  the  urine. 

Only  seen  as  isolated  little  cayenne-pepper  grains 
at  the  bottom  of  the  glass,  or  entangled  in 
mucus. 

Usually  seen  (if  at  all  by  naked  eye)  as  small 
shining  crystals  entangled  in  the  mucus. 

Practically  a  constant  feature  even  in  health ;  it 
forms  a  translucent,  semi-transparent,  floccu- 
lent  cloud  towards  the  lower  part  of  the 
glass,  and  often  floating  free  in  the  middle  of 
the  urine. 

White  or  greenish  white,  often  hummocky  deposit 
at  the  bottom  of  the  glass,  not  granular,  but 
easily  mistaken  for  phosphates  or  white  urates  ; 
mucus  cloud  usually  excessive  above  it ;  urine 
commonly,  though  by  no  means  invariably, 
ammoniacal. 

Smoky  or  definite  red  colour  of  blood,  light  or 
dark. 

Peculiar  greenish  yellow  tinge  in  typical  diabetic 
urine,  but  perhaps  more  often  nothing  very 
distinctive. 

Only  observable  under  the  microscope  ;  not  any 

characteristic  appearance. 
Vide  colour  and  chemical  changes,  p.  190 


^  Students  are  very  apt  to  forget  that  phosphates  of  sodium  and  potassium  are 
soluble  in  water,  and  therefore  do  not  occur  in  precipitates. 

■^  These  crystals  are  called  triple  phosphates,  because  all  three  atoms  of  hydrogen 
are  replaced  by  metals  (2  by  Mg,  i  by  Am)  ;  they  can  only  occur  when  decomposi- 
tion has  taken  place  in  the  urine,  either  within  or  without  the  body  ;  for  without 
decomposition  ammonia  does  not  appear  in  the  urine. 


PLATE 

URINARY    DEPOSITS 

1.  Uric  Acid. 

2.  Amorphous  and  Soda  Urates. 

3.  Triple  or  Ammonio-Magnesic  Phosphate. 

4.  Oxalates. 

5.  and  6.   Casts  of  Uriniferous  Tubes   x   215  Diam. 

To  face  page  192. 


,# 


Fig.  1.     Uric  Acid. 


i^^'-ff'' 


'^••A  '■'^■'^■^■-  ■■■■. 


^o^ 


Fig.  2.    Amorphous  &  Soda  Urates. 


'^- 


^ 


^^^  ^ 


Fig.  3.    Triple  or  Ammonio- 
Magnesic  Phosphate. 


Fig.  4.    Oxalates. 


.^& 


Oxalate. 


/.;! 
^ 


o    o, 


^'m. 


a   ^     c 


.  oc     ^#?.  ^^^^mrnmmm 


i^€ 


<:^ 


^ —  — 


\     o 


IViple  phospliate. 


Figs.  5  and  6.    Casts  of  Uriniferous  Tubes  x   215  Diam. 


URINARY      DEPOSITS. 


To  face  page  igz. 


VI  DISEASES  OF  THE  URINARY  ORGANS  193 

Heat  and  Chemical  Tests 

First  ascertain  by  litmus  paper  the  reaction  of  the  urine.  Inas- 
much as  all  the  deposits  may  occur  in  acid  or  alkaline  urine,  with 
the  exception  of  triple  phosphates  {vide  footnote,  pp.  192  and  209) 
and  excessive  urates,  an  alkaline  reaction  gives  no  very  definite 
information  beyond  a  strong  probability  that  a  deposit  is  not  urates, 
but  it  is  important  in  the  heat  test  for  albumen.^ 

Then  take  a  little  of  the  urine  in  a  clean  ^  test-tube  (if  there  be 
a  deposit  to  be  tested  take  care  to  get  plenty  of  it  in  the  test-tube), 
and  apply  heat  very  cautiously  and  gradually,  watching  the  urine 
carefully  all  the  time.  Bring  it  to  active  ebullition,  and  finally  add 
a  drop  of  nitric  or,  better  still,  acetic  acid. 

The  meaning  of  this  is  as  follows  : — 

1.  From  cold  up  to,  say,  a  little  below  blood  heat  urates  will 
gradually  dissolve: 

.'.  Watch  the  deposit  to  see  if  it  gets  lighter — the  diminution 
represents  urates ;  if  no  diminution  up  to  this  point,  no 
urates ;  and,  N.B. — all  urates  are  now  dissolved,  and  so 
cannot  be  mistaken  for  albumen. 

2.  From  about  blood  heat  up  to  boiling  albumen  will,  if  present, 
be  coagulated  and  appear  as  a  precipitate ;  the  more  albuminous  a 
liquid  the  lower  the  temperature  at  which  the  albumen  will  begin  to 
coagulate : 

.  •.  Watch  the  deposit  (or  clear  urine)  to  see  if  it  gets  thicker  (or 
clouds). 

Any  precipitate  now  appearing  is  either  albumen  or  phos- 
phates,^ and  neither  will  disappear  on  boiling,  so  we  add  one  drop 
of  acid  (acetic  is  best,  as  it  is  weaker  and  so  avoids  fallacies  of 
nitric  dissolving  traces  of  albumen),  which — 

3.  Dissolves  any  phosphates,  but  (if  not  too  much  be  added) 
leaves  the  coagulated  albumen  untouched : 

^  This  is  owing  to  the  fact  that  when  decomposition  takes  place  any  albumen 
present  is  converted  by  the  ammonia  into  alkali-albumen,  which  is  not  coagxilated  by 
heat  alone. 

2  Dirty  test-tubes,  especially  with  acid,  will  often  prevent  precipitation  of 
albumen. 

3  It  is  doubtful  to  what  cause  this  deposition  of  phosphates  is  due  ;  possibly  escape 
of  CO2  which  held  them  in  solution,  or  possibly  some  subtler  chemical  change  in  them 
produced  by  boiling  (Ralfe), 

O 


194  DIFFERENTIAL  DIAGNOSIS  chap. 

.*.  The  part  of  final  precipitate  clearing  up  with  acid  =  phos- 
phates;  remainder  =  albumen  or  other  proteid  body;  if 
brownish  red,  probably  due  to  blood  or  stained  by  blood. 

4.  If  the  deposit  is  unaltered  or  only  slightly  thickened  by  boiling, 
it  is  either  phosphates  or  pus. 

Now  take  a  fresh  specimen  in  a  clean  test-tube,  and  add  a  drop 
or  two  of  acetic  acid  or  weak  nitric  acid,  this — 

Makes  mucin  stringy; 
Dissolves  phosphates ; 
Does  not  affect  urates  ; 
Does  not  materially  affect  pus. 

To  a  similar  specimen  add  a  few  drops  of  caustic  potash  ;  this — 

Causes  pus  to  become  jellified  or  ropy ; 

Dissolves  urates ; 

Does  not  affect  urates  markedly. 

To  test  for  sugar,  boil  some  Fehling's  solution,  and  while 
boiling  hot  add  a  few  drops  of  urine ;  if  sugar  be  present,  red  or 
yellow  oxide  of  copper  is  rapidly  precipitated.  There  are  many 
other  tests  for  sugar,  and  great  controversy  still  exists  as  to  which 
is  the  best ;  but  the  above,  known  as  Fehling's  test,  is  sufficient 
and  accurate  enough  for  ordinary  clinical  purposes. 

If  bile  be  suspected  by  the  colour,  Pettenkofer's  test  with  fuming 
nitric  acid,  giving  a  play  of  colours  if  bile  pigments  be  present,  may 
be  applied  as  confirmatory  evidence.  But  the  simplest  of  all  tests 
for  bile  is  the  yellow  colour  imparted  to  the  froth  that  appears 
when  urine  is  shaken. 


Microscopical  appearances  of  Urinary  Deposits  and  Elements 

Oxalates. 

Phosphates —  Amorphous  or  crystalline. 

Triple  phosphates. 

Pus. 

Blood  cells. 

Urates. 

Uric  acid. 

Casts. 


VI  DISEASES  OF  THE  URINARY  ORGANS  195 


CLINICAL  SIGNIFICATION  OF  ABOVE 

We  may  now  proceed  to  discuss  more  fully  the  second  question 
mentioned  above,  viz.  What  is  the  clinical  significance  of  the  various 
morbid  constituents,  and  how  far  are  they  of  diagnostic  value  ? 

Albuminuria 

The  causes  that  may  produce  albumen  in  the  urine  are  many, 
but  we  can  distinguish  in  clinical  work  three  groups  of  albuminuria  : — 

Group  I. — In  which  the  albumen  is  only  a  sub-     Blood  {vide  Haema- 
sidiar}'-    factor,    and    its    presence     completely  turia). 

accounted  for  by  the  other  constituent,  viz. —        Pus  {vide  Pyuria). 

Spermatorrhoea  (?). 
Group  II. — Present     With    abundant    casts,    indicating    acute    kidney 
with  other  factors  disease,    or    consecutive    nephritis     in    earlier 

explaining  its  an-  stages, 

atomical     source, 
viz. — 
Group       III.  —  In      Cirrhotic  kidney. 

which  it   is   often     Consecutive  nephritis  in  later  stages, 
the   only   obvious      Lardaceous  kidney. 
morbid     constitu-     Surgical  kidney  (hydro-nephrosis). 
ent,  though  a  few     Stone  in  pelvis,  probably  with  pus  or  crystals, 
casts    or    crystal-     Cardiac  disease  or  general  back  pressure, 
line       substances     Abdominal  disease  or  pregnancy,  with  local  back 
may  be  present  in         pressure. 

some  cases.  With  or   after  some  specific  fevers — diphtheria, 

scarlet  fever,  etc. 
So-called  cyclical  or  functional  albuminuria. 
Leucorrhea  in  women. 
Anaemia  (occasionally). 
Debility  in  or  after  many  general  diseases. 

To  determine  to  which  of  these  groups  a  given  case  belongs  it 
is  obvious,  then,  that  we  must  examine  the  urine  carefully  (and 
repeatedly  in   some    cases)  by  chemical  and  microscopicaP   tests. 

^  If  no  obvious  deposit  is  present  let  the  urine  stand  for  twelve  hours  in  a  conical 
vessel  covered  from  dust.  The  late  Dr.  Ralfe  used  also  to  dust  a  little  powdered 
starch  on  its  surface,  to  carry  down  mechanically  any  floating  casts.  If  a  centrifugal- 
ising  machine  is  available  this  is  the  best  method  of  obtaining  a  deposit. 


196  DIFFERENTIAL  DIAGNOSIS  chap. 

These  will  be  practically  certain  to  differentiate  Groups  I.  and  II., 
and  by  exclusion  lead  us  to  believe  that  some  member  of  Group  III. 
is  causing  the  mischief. 

Then  note  the  quantity  of  albumen  present ;  if  only  a  trace,  it 
is  most  likely  due  to — 

Cirrhotic  kidney. 

Back  venous  pressure  (local  or  general). 

Surgical  kidney  (first  or  second  stage,  q.v,\ 

Specific  fevers  (not  reaching  stage  of  actual  nephritis). 

Leucorrhea. 

Anaemia. 

Cyclical  or  functional  {^q.v.\ 

If  more  than  a  trace,  probably — 

Lardaceous  kidney,  or 

Consecutive  nephritis  without  many  casts,  or 

Chyluria. 

Most  of  these  conditions  will  become  tolerably  obvious  when 
the  patient  as  well  as  his  urine  is  carefully  overhauled,  but  one  or 
two  of  them  require  a  little  further  consideration. 

Cyclical  or  Functional  Albuminuria 

These  are  terms  invented  to  describe  cases  which  were,  I 
believe,  first  noticed  by  examiners  for  life  assurance  (but  the  con- 
dition has  subsequently  been  investigated  by  many  observers),  who 
found  albumen  in  the  urine  without  obvious  cause,  and  with  an 
entire  absence  of  other  guiding  pathological  constituent  or  even 
symptom.  Its  exact  pathology,  and  above  all  its  precise  clinical 
significance  from  a  prognostic  point  of  view,  are  still  but  imperfectly 
understood,  but  before  we  can  allow  ourselves  to  rest  content  with 
such  a  diagnosis,  the  following  propositions  and  conditions  must 
have  been  rigorously  investigated  : — 

1.  That  the  patient  must  have  been  most  carefully  examined  in 
every  system,  without  finding  evidence  of  disease  (more  especially, 
perhaps,  the  condition  of  the  vascular  system). 

2.  That  the  urine  and  the  urinary  system  must  have  been  also 
repeatedly  and  carefully  examined  without  the  discovery  of  any 
morbid  constituent  or  local  condition,  especially  casts,  blood,  pus, 
stricture,  stone,  phimosis,  leucorrhea,  fever,  phthisis,  leucocythaimia, 
etc. 


VI  DISEASES  OF  THE  URINARY  ORGANS  197 

3.  That  the  albumen  shall  never  have  been  more  than  a  trace. 

4.  It  is  a  condition  hitherto  found  almost  exclusively  in 
adolescents  (boys  or  girls),  or  youngish  adults,  though  it  is  uncertain 
how  far  it  may  persist  into  later  life. 

5.  The  circumstances  found  to  influence  the  presence  and 
quantity  of  the  albumen  have  usually  been  position  of  body,  exer- 
cise, exposure,  and  certain  articles  of  diet,  e.g.  eggs  j  and  hence  the 
urine  must  be  examined  on  several  occasions — 

Before  and  after  rising  in  the  morning ; 
„  „    cold  bathing; 

„  ,,    food  of  suspected  kinds ; 

„  ,,    exertion  (slight  and  severe). 

If  these  various  testings  give  various  results  while  other  condi- 
tions remain  the  same,  a  preliminary  diagnosis  of  functional  may 
be  given,  but  one  to  be  willingly  abandoned  on  the  discovery  of 
some  indisputably  organic  change. 

Surgical  Kidney  as  Cause  of  Albuminuria 

Surgical  kidney  is  a  convenient,  but  somewhat  invidious,  expres- 
sion used  to  denote  a  kidney  which  has  been  damaged  by  obstruction 
to  the  free  outflow  of  urine  from  its  pelvis.  It  would  appear  that 
an  intermittent  obstruction  is  equally,  if  not  more,  efficacious  than  a 
permanent  one  in  producing  the  condition. 

In  its  typical  form  it  is  essentially  a  surgical  trouble  with  surgi- 
cal treatment,  and  its  description  and  discussion  must  be  looked  for 
in  surgical  manuals ;  but  as  its  earlier  manifestations  and  irregular 
forms  may  easily  come  before  a  physician,  its  main  features  are  here 
glanced  at. 

There  are  three  forms  or  stages  of  it  readily  distinguishable 
when  met  with  alone,  but  they  are  far  more  usually — on  the  post- 
mortem table  at  any  rate — mixed  with  one  another : — 

1.  Simple  atrophy  of  pyramids  from  pressure. 

2.  No.  I,  plus  chronic  inflammation  of  kidney  from  irritation. 

3.  No.  I  and  No.  2,  plus  septic  infection  of  the  urinary  tract. 

As  regards  the  causation,  there  are  three  well-known  causes,  viz. 
stricture  of  urethra,  stone  in  the  bladder,  and  enlarged  prostate, 
and  when  either  of  these  is  in  operation  it  is  probable  that  both 
kidneys  will  suffer.  The  disease  is  here  mentioned  in  a  medical 
work  chiefly  on  account  of  a  group  of  cases  which  arise  from  very 


198 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


ill-understood  causes  that  are  supposed  to  give  rise  to  intermittent 
kinking  of  the  ureter,  with  a  consequent  intermittent  increase  of 
pressure  in  the  pelvis. 

Definite  diagnosis  of  such  cases  is  in  all  probability  impossible 
in  their  earlier  stages,  but  the  following  symptoms  would  render  the 
condition  highly  probable  : — 

1.  Albuminuria  probably  not  more  than  a  trace,  and  very  pos- 

sibly intermittent. 

2.  Marked  irregularity  in  the  quantity  of  urine  passed  in  succes- 

sive days. 

3.  The  presence  in  the  abdomen  of  a  tumour,  possibly  ill-defined, 

diminishing  and  increasing  according  as  the  amount  of 
urine  passed  is  large  or  small. 

The  remaining  conditions  of  albuminuria  in  Group  III.  may  be 
more  briefly  dismissed  in  tabular  form : — 


2. 


Condition. 

Cirrhotic  kidney^ 
or  consecutive 
nephritis  i?i  the 
later  stages. 

Lardaceous  kid- 
ney. 


3.  Heart  disease. 


4.  Abdominal      dis- 

ease. 

5.  Nephrolithiasis. 

6.  Diphtheria^  scar- 

let fever.,  or 
other  zymotic; 
ancemia^  leucor- 
rhea^  convales- 
cence from  even 
acute  nephritis. 


Guiding  Indications. 

Specific  gravity  low ;  quantity  increased ;  heart 
hypertrophied  ;  vessels  probably  degenerate  ; 
distinct  history  of  nephritis  in  consecutive 
cases. 

Albumen  considerable  ;  quantity  of  urine  greater 
than  usual ;  some  obvious  cause  for  lardaceous 
change,  not  forgetting  syphilis  and  phthisis  ; 
liver  or  spleen,  or  both,  almost  sure  to  be 
enlarged ;  painless  diarrhoea  may  (rarely)  be 
present. 

Bruits  probably  present,  or  at  least  alterations 
from  health  in  the  cardiac  sounds  ;  nearly  sure 
to  be  oedema  of  legs  ;  quantity  of  urine  di7ni?t- 
ishi7tg  lately.,  pari  passu  with  the  onset  of  other 
back  pressure  symptoms. 

Ascites  or  tumour  or  pregnant  uterus  ;  swelling 
of  abdomen  probably  obvious. 

Vide  Stone  in  Kidney. 

The  history  of  such  disease  is  usually  obvious 
enough  ;  albumen  likely  to  diminish  as  convale- 
scence proceeds,  but  casts  must  be  anxiously 
looked  for. 


In  connection  with  all  the  groups,  but  especially  perhaps  with 


VI  DISEASES  OF  THE  URINARY  ORGANS  199 

this  last  group,  of  causes  of  albuminuria,  a  very  anxious  question  will 
often  arise — Is  this  patient  weak  and  anaemic  because  he  is  albu- 
minuric, or  is  he  albuminuric  because  he  is  weak?  The  question 
is  important  because  of  treatment.  If  we  feed  him  up  to  cure 
anaemia  we  may  further  damage  his  kidneys :  if  we  starve  him  to 
relieve  the  kidneys  we  may  perpetuate  the  anaemia,  and  also  the 
debility  of  renal  tissue.  To  answer  this  question  fully  would  require 
an  essay,  but  the  following  points  are  worthy  of  attention  : — 

It  is  obvious  at  once  that  all  albuminuria  depends  upon  and  is 
caused  by — 

(i)  Acute  or  gross  disease  in  or  near 

(2)  Simple  nutritive  (or  original)  debility  of 

some  part  of  the  kidney  structures,  which,  when  healthy,  prevents 
or  does  not  cause  a  transudation  of  albumen  into  the  excretion. 
Acute  or  gross  disease  includes — 

(a)  All  those  cases  (stone,  tubercle,  carcinoma,  perirenal  abscess, 
etc.),  the  treatment  of  which  is  or  should  be  almost  entirely  surgical, 
and  of  which  a  brief  note  will  be  found  under  the  appropriate 
heading. 

(d)  Inflammation  of  the  kidneys  or  bladder,  of  which,  when 
acute,  the  treatment  and  management  are  obvious  enough. 

Difficulties  and  doubts  arise  when  the  acute  trouble  has  subsided 
and  the  case  become  one  in  which  the  albumen  remains  (with  the 
anaemia  in  the  secondary  cases,  possibly  without  it  in  the  primary 
ones)  as  practically  the  only  sign  of  disease.  These  must  be  placed 
for  our  present  object  along  with  the  group  in  which  no  such  acute 
local  trouble  has  been  present.  The  following  important  proposi- 
tions may  then  be  made  on  them,  each  proposition  having  weighty 
therapeutical  deductions : — 

1.  Albuminuria  of  so-called  functional  or  cyclical  origin  may 
exist  for  years  without  the  subject  of  it  showing  any  marked  deterio- 
ration of  health,  and  the  same  is  true  of  many  albuminurias  which 
are  the  sequel  of  known  acute  Bright's  or  other  gross  renal 
mischief. 

2.  If  the  urine  on  boiling  becomes  practically  solid,  this  only 
means  about  2  per  cent  of  albumen — say  the  equivalent  of  an  egg 
or  a  couple  of  ounces  of  beefsteak  in  twenty-four  hours ;  while  what 
is  ordinarily  spoken  of  as  a  trace  of  albumen  means  from  J  to 
^  per  cent  or  less — the  equivalent  of  about  one  ordinary  mouth- 


200  DIFFERENTIAL  DIAGNOSIS  chap. 

ful  of  food — so  that  as  a  mere  drain  of  nutrient  material  from  the 
body  albuminuria  may  be  certainly  neglected. 

3.  Experience  has  shown,  after  many  trials,  that  no  drug  and  no 
plan  of  low  diet  expressly  used,  ad  hoc,  has  hitherto  been  found 
capable  of  preventing  or  eliminating  the  last  traces  of  albumen  from 
the  urine. 

4.  It  is  the  life-work  of  the  kidneys  to  excrete  some  of  the 
waste  products  from  the  body,  and  these  oxidation  products  come 
from  two  sources  : — 

{a) .  The  result  of  the  ordinary  never-ceasing  activity  (life,  growth, 
and  decay)  of  all  the  body  tissues  and  cells. 

(b)  A  possible,  or  even  probable,  luxus  consumption  of  materials 
taken  in  by  the  mouth  as  food,  but  never  really  assimilated  into  the 
structures  of  the  body. 

Now,  any  rational  system  of  management  of  albuminuria  must 
take  all  these  facts  into  account.  Wear  and  tear  of  tissues  cannot 
be  checked  entirely,  but  it  may  be  kept  within  moderate  limits  by 
avoiding  excessive  physical  exertion.  Luxus  consumption  can  also 
probably  not  be  entirely  avoided,  but  may  be  reduced  considerably 
by  avoiding  excess  of  nitrogenous  food.  Beyond  these  extremes  I  do 
not  think  we  should  be  too  strict  either  in  diet  or  exercise  with 
albuminurias,  for  constant  worry  of  obeying  rules  is  worse  than 
occasional  lapses  from  them. 

Pyuria  or  Pus  in  the  Urine 

The  sources  of  pus  found  in  the  urine  may  thus  be  tabulated, 
with  their  most  prominent  guiding  features : — 

Source.  Chief  Points. 

Urethra,  in  either  Quantity  small ;  escapes  at  any  time,  indepen- 
sex.  dently  of  micturition,  and  stains  and  stiffens  the 

linen  ;  micturition  probably  painful  ;  squeezing 
urethra  towards  meatus  shows  a  bead  of  pus. 

Vagina  in  female.  Similar  indications,    and   speculum   clinches    the 

diagnosis ;  also  vaginal  epithelium  revealed  by 
microscope. 

Bladder^  Most  probably  associated  with  frequent  distress- 

ing micturition  and  other  symptoms  of  cystitis  \ 
urine  possibly  ammoniacal  on  voidance  ;  much 
bladder  epithelium  under  microscope ;  if  no 
symptoms  (or  very  slight)  of  cystitis,  pus  prob- 


VI 


DISEASES  OF  THE  URINARY  ORGANS 


20I 


Source. 


Ureter. 

Kidney    and  pelvis 
thereof. 


Chief  Points. 

ably  in  small  quantity,  but  the  cystoscope  must 
be  appealed  to  as  final  arbitrator. 

Practically  indistinguishable  from  kidney. 

Quantity  usually  considerable  ;  stone  and  tubercle 
most  common  causes  ;  urine  most  commonly 
acid,  and  but  little  disturbance  in  frequency  of 
micturition,  except  in  stone ;  pain  of  a  colicky 
nature  not  unfrequent ;  renal  epithelium 
frequently  found  under  the  microscope. 


If  we  have  ascertained  the  place  of  origin  of  the  pus,  the  next 
point  is  the  cause  of  the  suppuration  itself : — 


2.  In     vulva 
vagina. 


I.  In  urethra.  Hunterian  chancres  have  been  known  to  occur  in 

the  urethra ;    the  finger  would   readily  detect 
them  ;  instrumental  irritation. 

Strain  has  lately  been  asserted  on  good 
authority  to  cause  a  urethritis  independently  of 
sexual  connection. 

Gonorrhoea,  recent  or  old  (with  stricture),  is, 
after  all,  far  and  away  the  commonest  cause. 
If  the  matter  is  legally  disputed  the  gonococcus 
would  be  the  only  possible  distinctive  feature, 
though  this  is  more  likely  to  lead  to  hard 
swearing  than  to  scientific  conviction. 
and  Such  causes  as  foreign  bodies  (pessaries,  etc.)  are 
obvious  on  inspection  with  a  speculum,  as  are 
also  chancres,  epithelioma,  etc. 

It  is  indisputably  proved  that  in  young  sub- 
jects dirt,  masturbation,  etc.,  may  start  a  sup- 
purative  inflammation  without   a  suspicion   of 
criminal  violence.     A  diagnosis  without  a  his- 
tory is  impossible,  but  the  fact  of  such  vulvitis 
occurring  must  be  remembered  by  a  medical 
jurist. 
That  suppuration  may  occur  in  the  bladder,  or  at 
least  that  pus  may  enter  the  urinary  tract  at 
the  bladder  without  general   cystitis,  is  true  ; 
but   its  occurrence  is  so  rare   that  practically 
the    causes     of    cystitis    and    of    suppuration 
through   or   from  the  bladder  are  the  same. 
They  are  : — 


3.  In  Bladder, 


202 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


{a)     Foreign 
bodies. 


(b)  Distension 
from 


{c)  Extension  of 
inflamma  - 
tion. 

{d)  Debility. 


(<?)  Ulcers — 
Simple,      tu- 
b  e  re  u  1  a  r, 
malignant, 
primary,     or 
extending  to 
bladder  from 
other  organs, 
especi  ally 
uterus. 
From        kidneys 

and  ureters. 


Stone, — Proved  by  the  sound. 

Faeces  or  septic  pus, — History  of  illness,  such  as 

typhoid,  parametritis,   pyosalpinx,  which  could 

give   rise    to   entero-cystic    fistula    or    abscess 

bursting  into  the  bladder. 
Bits  of  catheter,  etc, — History  generally  admitted, 

but  may  be  only  recognised  by  the  sound. 
Stricture   of   urethra, — Proved    by   the    catheter 

and  history  of  difficult  micturition. 
Enlarged  prostate. — Found  by  catheter  or  finger 

in  rectum. 
Simple    atony,  —  Residual    urine    drawn    off  by 

catheter. 
Uterine  enlargement  or  puerperium  ;  obvious. 
History  of  acute   urethritis   or  vaginitis,  possibly 

diphtheritic. 

Cystitis  arises  in  the  very  old  or  very  young,  or  in 
patients  debilitated  by  any  illness,  from  very 
trivial  causes,  entirely  overlooked  perhaps,  and 
not  operative  in  health,  e.g.  clean  coitus,  clean 
catheter. 

The  tubercle  bacillus  or  fragments  of  a  neoplasm 
if  present  will,  of  course,  settle  the  matter  for 
two  of  these,  but  otherwise  to  be  certain  of 
them  is  impossible  without  the  aid  of  the 
cystoscope. 


The    causes    of   suppuration   from    kidneys    and 
ureters  are  not  very  numerous. 


Tubercle. 


Stone. 


Principal  Points 

Pus  abundant  (may  be  none,  vide  Tubercle  of 
Kidney),  and  haemorrhage,  too,  not  unfre- 
quent ;  tubercle  bacilli  in  pus  ;  renal  colic  not 
unfrequent ;  possibly  tubercle  elsewhere.  Age  : 
middle  life  usually. 

Pus  as  a  rule  not  very  abundant  ;  colic  common 
{vide  Nephrolithiasis).  Age  :  children  and  old 
people  very  prone  to  it,  but  no  age  exempt. 


VI 


DISEASES  OF  THE  URINARY  ORGANS 


203 


Malignant      dis- 
ease. 


Pyaemia. 


Perinephritic  ab- 
scess. 


Pus  not  much  ;  haemorrhage  more  likely  {vide 
Kidney  Cancer).  Age  :  late  adult  life,  except 
rapidly  growing  sarcomata,  which  are  almost 
confined  to  children. 

Either  extension  from  the  bladder,  when  the 
cystitis  will  mask  the  kidney  symptoms,  or  a 
cause  of  general  pycemia  present  ;  in  either 
case  renal  features  quite  subordinate. 

History  of  increasing  pain  and  swelling  in  the 
loin  ;  pus  in  urine  increasing  or  diminishing 
with  diminution  or  increase  in  tumour,  and 
often  quite  intermittent. 


In  all  the  above  renal  troubles  if  pain  or  tenderness  be  marked 
on  one  side,  and  not  on  the  other,  or  if  a  ver}^  distinct  tumour  be 
felt  by  abdominal  examination,  the  kidney  at  fault  will  easily  be 
known  ;  but  it  is  a  very  common  thing  for  the  diagnosis  to  remain 
in  doubt  until  the  cystoscope  has  been  used,  showing  something 
abnormal  in  or  of  the  ureteral  orifice  of  the  affected  kidney. 

HEMATURIA 

Blood  like  pus  may  come  from  any  part  of  the  urinary  tract,  and 

in  the  main  the  indications  of  its  source  are  similar. 


Urethra. 


Prostate. 


Chief  Indications 

Is  pure,  and  escapes  at  any  time,  thus  staining 
the  clothes  ;  probable  history  of  traumatism  or 
instrumentation. 

Blood  from  prostate  either  gets  into  the  bladder, 
or  trickles  down  the  urethra ;  in  either  case 
the  prostate  would  only  be  suspected  if  other 
symptoms  of  enlarged  prostate  had  occurred, 
or  if  digital  or  instrumental  examination  had 
revealed  prostatic  abnormalities. 


Table  of  Differences  of  H^ematuria  from 


Bladder. 
Usually  very  obvious  blood  \  often 
irregular  clots  in  it ;  blood  fre- 
quently by  itself. 


Kidneys. 

IMore  commonly  a  smokiness,  not 
obviously  blood,  more  intimately 
mixed  with  urine  ;  if  clots,  they 
will  have  shape  of  ureter. 


204 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Bladder. 
No    renal  casts  ;  possibly  bladder 
epithelium. 

Strangury  ^  a  less  common  associa- 
tion. 

If  any  local  pain  it   Is  in  bladder 

region,  or  at  end  of  penis. 
Never  haemoglobinuria  only. 


Kidneys. 

If  from  renal  substance,  almost  in- 
variably blood  casts  of  renal 
tubules. 

Strangury  a  common  association, 
e.g.  after  taking  turpentine  or 
application  of  cantharides. 

If  any  local  pain  it  is  in  renal  region, 
or  in  groin  and  testes. 

May  be  only  haemoglobinuria,  i.e. 
no  evident  corpuscles. 


Notwithstanding  these  indications,  the  cystoscope  will  frequently 
have  to  be  used  to  clear  up  the  diagnosis. 

Tubercle  bacilli  or  bits  of  malignant  growth  may  occur  in  either, 
and  offers  no  assistance  in  localising  diagnosis. 

If  we  decide  that  the  blood  comes  from  the  kidney,  we  have  the 
following  points : — 

From  Hilum.  From  Substance. 

Free       haemorrhage     Smokiness  merely,  and  casts  of  renal  tubules  ;  if 
and  ureteral  casts.  haemorrhage    is   free  traumatic  history  almost 

invariable. 
Never  haemoglobin-     Often  haemoglobinuria  only. 


una. 


Frequently 
ated  with  pus 


associ- 


Practically  never  with    pus,    the  only   exception 
being  pyaemia. 


As  with  pus,  we  must  consider  the  diagnosis  of  the  cause  of  the 
haemorrhage. 


1 .  From        urethra, 

vagina,    and 
vulva. 

2.  From  prostate — 

Carcinoma. 

Abscess. 


Varicose  veins. 


Traumatism,  carcinoma,  etc.  ;  the  parts  are  so 
open  to  inspection  that  nothing  further  need 
be  said. 

Enlargement    revealed   to    examining   finger    in 

rectum  ;  chronic  history  of  local  pain. 
Tenderness     to    finger ;     possibly    a    fluctuating 

swelling  ;    acute    history  of   prostatic    trouble ; 

pus  with  the  blood. 
These     unquestionably     exist    on    an    enlarged 

prostate  and  at  the  base  of  bladder,  and  may 


^  "  Strangury"  is  a  term  used  to  express  a  pathologically  excessive  desire  to  pass 
water,  with  frequent  attempts  to  fulfil  the  desire  :  it  is  a  symptom  of  excessive  irrita- 
tion of  kidneys,  and  probably  reflexly  of  the  prostate  too. 


VI 


3.   Bladder, 


4.   Kidney. 


DISEASES  OF  THE  URINARY  ORGANS  205 

give  rise  to  severe  hasmorrhage  ;  their  presence 
will  chiefly  be  guessed  at  by  the  absence  of 
other  causes  ;  only  the  cystoscope  can  prove 
their  presence. 

The  causes  of  haemorrhage  from  the  bladder  are 
the  same  as  those  of  pus  {q.v.)  with  the  excep- 
tion of  simple  varicose  veins,  and  innocent 
papillomata.  In  the  late  stages  the  diagnosis 
will  be  self-evident ;  in  the  earlier  stages  the 
cystoscope  or  sound  is  simply  and  absolutely 
indispensable  ;  without  one  or  possibly  both  of 
them  diagnosis  is  impossible. 

Unless  one  of  the  following — heart  disease  (for 
infarcts),  tubercle  bacilli,  fragments  or  new 
growth,  or  tumour  in  loin — is  present,  and 
reveals  by  its  presence  or  by  its  character  the 
nature  of  the  kidney  trouble,  we  may  say  at 
once  that  exact  diagnosis  of  the  cause  of  renal 
haemorrhage  is  impossible  without  exploration. 
Acute  nephritis  (with  its  attendant  general 
symptoms),  hemophilia,  and  those  cases  in 
.vhich  only  some  form  of  blood  pigment  (with- 
out corpuscles)  is  present,  are  of  course  ex- 
cepted ;  their  diagnosis  being  more  from 
general  considerations  than  through  the  local 
haemorrhage.  I  have  seen  very  obstinate  renal 
hsemorrhage  follow  influenza  without  an}thing 
occurring  to  give  any  hint  of  a  more  definite 
diagnosis.  Stone,  tubercle,  and  carcinoma  are 
far  the  most  frequent,  and  must  be  suspected 
until  other  cause  can  be  found  or  definitely 
excluded. 


CASTS 


To  mention  all  casts  possibly  found  in  urine  it  must  be  stated 
that  urethral  or  ureteral  casts  may  be  met  wdth ;  they  will,  however, 
usually  be  recognisable  by  the  naked  eye,  and  will  be  simply  blood 
clots.     They  have  been  sufficiently  noticed  under  Haematuria. 

It  remains,  therefore,  to  enumerate  the  various  kinds  of  renal 
microscopic  casts  that  are  met  wdth,  and  consider  their  value  as 
diagnostic  factors.     As  a  convenient  method  of  remembering  them, 


2o6  DIFFERENTIAL  DIAGNOSIS  chap. 

we  may  put  them  down  in  the  order  in  which  they  must  occur  in  a 
case  of  acute  nephritis  from  the  stage  of  congestion  onwards.  Thus 
we  shall  have — 

1.  Small  hyaline  casts  from  simple  coagulated  serum  exuded  in 

the  early  hours  of  congestion,  generally  overlooked  owing 
to  the  rapid  production  of — 

2.  Blood  casts,  which  form  from   the  blood  escaping  into  the 

uriniferous  tubules  in  the  next  stage  of  the  inflammatory 
process  ;  inflammation  rapidly  causes  the  death  of  renal 
epithelium,  and  consequently — 

3.  Epithelial  casts  soon  follow,  formed  of  masses  of  rapidly-shed 

epithelium.  That  which  at  first  remains  attached  to  its 
membrane,  but  eventually  dies,  undergoes  degeneration, 
and  disappears  from  the  tubules  as — 

4.  Granular  casts, — if  the  cells  degenerate  so  as  to  lose  their  out- 

line, and  become  mere  granular  detritus,  or — 

5.  Fatty  casts — if,  on  the  other  hand,  the  degeneration  takes 

a  fatty  form ;  and  certainly  in  the  later  stages  of  nephritis, 
when  the  acute  inflammatory  phenomena  have  subsided, 
fatty  casts  are  more  abundant.      Lastly — 

6.  Large  hyaline  casts  are  formed  by  the  coagulation  of  an  ex- 

udation taking  place  into  tubes  denuded  of  their  epithelium, 
and  consequently  with  larger  calibre. 

Provided  that  the  secretion  of  urine  is  fairly  free,  the  relative 
abundance  of  any  of  these  casts  gives  a  rough  estimate  of  the 
rapidity  with  which  epithelium  is  dying  and  being  shed.  So  that 
from  a  clinical  point  of  view  the  abundance  and  the  nature  of  the 
predominant  form  of  cast  may  be  able  to  give  us  some  idea  of  the 
progress  of  the  case.  Thus  blood  casts  will  not  be  likely  to  pre- 
dominate in  any  case  that  is  improving;  fatty  casts  rather  point 
to  a  want  of  recuperative  power  in  the  kidneys,  while  a  large  total 
number  of  casts  of  epithelial  origin  point  to  a  grave  destruction  of 
renal  substance  still  going  on. 

Beyond  these  hints,  casts  are  of  comparatively  little  value  in  a 
case  of  acknowledged  and  definite  nephritis ;  but  it  is  in  cases  of 
less  definite  character,  and  more  insidious  onset,  where  albuminuria 
first  draws  serious  attention  to  the  renal  function  that  the  prese?ice 
of  casts  is  such  an  important  point  to  determine.  Thus,  in  the 
following  conditions  more  especially  (though  in  no  case  of  albumin- 
uria must  repeated  searches  for  casts  be  omitted),  the  presence  of 
casts  must  give  us  serious  concern  for  the  safety  of  our  patient. 


VI  DISEASES  OF  THE  URINARY  ORGANS  207 

1.  Pregnancy. 

2.  Any  abdominal  tumour  likely  to  cause  pressure  on  kidneys 

or  renal  vessels. 

3.  Any  case  in  which  serious  surgical  procedures  of  any  kind  are 

contemplated. 

4.  Convalescence  from,  or  presence  of,  scarlet  fever,  diphtheria, 

and  in  fact  any  acute  illness,  especially  of  microbic  origin. 

5.  In  a  case  hitherto  regarded  as  functional  albuminuria. 

The  presence  of  numerous  casts  shows  that  the  albuminuria  is 
probably  due  to  something  more  than  slight  nutritive  weakness  of 
the  kidney,  and  therefore  ceteris  paribus  adds  enormously  to  the 
gravity  of  the  situation. 

URATES 

It  is  well  to  remember  that  this  is  the  only  deposit  that  occurs 
in  urine  (which  has  not  decomposed)  as  the  result  of  simple  cooling, 
and  hence  when  the  means  are  not  at  hand  for  properly  testing  the 
secretion,  if  the  urine  was  bright  and  clear  on  voidance,  a  patient's 
mind  can  often  be  set  at  rest  at  once  by  finding  that  the  secretion 
was  clear  until  it  cooled. 

We  have  already  noticed  that  urates  are  often  enough  present 
in  large  quantities  in  health,  under  various  conditions  of  exercise 
and  weather,  etc.  Their  pathological  associations  are  as  numerous 
as  the  whole  nomenclature  of  diseases,  for  there  is  no  illness  which 
may  not  be  associated  with  (?  actually  cause)  a  deposit  of  urates  in 
the  urine.  As  a  matter  of  practical  clinics,  therefore,  their  diag- 
nostic value  or  importance  is  not  great,  but  we  must  generally 
suspect  when  urates  are  in  excess 

1.  Febrile  disorders  of  some  kind,  especially  rheumatism  ;  or — 

2.  Alimentary  disturbance,  and  especially  if  gout  be  in  question. 

In  the  former  class  they  probably  indicate  an  insufficiency  of 
oxygen  to  burn  up  the  increased  waste  products ;  in  the  latter  some 
slight  disturbance  of  the  course  of  the  body's  metabolism ;  in  either 
case  they  may  be  said  generally  to  indicate  the  necessity  for  a  free 
evacuation  of  the  bowels,  and  due  attention  to  the  organs  of 
digestion. 

Their  relationship  to  stone  will  be  briefly  referred  to  under  that 
head. 


2o8  DIFFERENTIAL  DIAGNOSIS  chap. 


OXALATES 

These  are  comparativexy  unfrequent  elements  in  a  deposit,  and 
but  little  is  known  of  their  causation  beyond  the  fact  that  they  may 
occur  in  quantity  after  a  meal  in  which  rhubarb  or  sorrel  leaves  has 
been  freely  partaken  of.  A  few  doses  of  nitro-hydrochloric  acid 
will  rapidly  remove  them  from  the  urine,  and  the  aching  pain  from 
the  back,  the  latter  being  their  only  known  symptom. 

PHOSPHATES 

Phosphorus  in  combination  appears  in  the  urine  in  four  groups 
of  bodies,  viz. — 

1.  In  combination  with  organic  radicals  in  the  shape  of  lecithin, 

protagon,  etc.,  the  existence  of  which  is  well  recognised  in 
the  excretion ;  but  the  results  of  their  estimation  and  the 
significance  of  their  presence  are  not  yet  available  for 
ordinary  clinical  work,  and  therefore  nothing  further  will 
be  said  about  them. 

2.  As  the  phosphates  of  the  fixed  alkalies  Na  and  K. 

3.  As  the  phosphates  of  the  alkaline  earths  Ca  and  Mg. 

4.  Triple  phosphates. 

On  these  last  three  groups  a  word  or  two  may  be  said. 

(2)  Phosphates  of  Sodium  and  Potassium. — We  have  already  noted 
these  bodies  as  the  chief  cause  of  the  acidity  of  the  urine.  The  only 
other  caution  connected  with  them  is  to  remember  that  they  are  so 
freely  soluble  in  water  that  they  never  in  untreated  urine  form  any 
part  of  the  very  common  phosphatic  deposit.  This  caution  is  the 
more  necessary,  as  a  student  almost  invariably  replies,  "  Sodium  and 
potassium  "  if  asked  what  phosphates  are  present  in  a  deposit. 

(3)  Phosphates  of  Ca.  and  Mg. — These  are  the  phosphates  which 
are  precipitated  on  boiling,  or  in  a  urine  which  is  acid  without 
artificial  treatment.  So  long  as  they  appear  only  on  boiling,  or  as 
a  scarcely  appreciable  quantity  in  an  otherwise  healthy  urine,  they 
may  be  neglected  in  diagnosis  \  but  when  they  appear  in  distinctly 
measureable  quantities  they  assume  at  once  a  position  of  greater 
importance,  and  a  few  points  will  be  noticed  {vide  Phosphatic 
Diabetes). 

(4)  Triple  Phosphates. — The  name  "triple,"  though  sanctioned 
by  long  usage,  seems  to  me  somewhat  badly  chosen,  because,  unless 


VI  DISEASES  OF  THE  URINARY  ORGANS  209 

one  is  very  careful  to  explain  the  nature  of  these  crystals,  students 
jump  to  the  conclusion  that  triple  means  that  three  metals  are 
combined  with  the  phosphoric  acid  instead  of  understanding  that 
all  three  atoms  of  hydrogen  are  replaced,  two  by  the  dyad  Mg,  and 
one  by  the  monad  Am,  so  that  the  formula  is  Mg  Am  PO^, 
and  aq. 

The  only  clinical  deduction  their  presence  allows  is,  "This  urine 
has  decomposed." 

Why  this  deduction  ? 

Because  there  is  no  other  available  source  for  the  Am  except 
that  provided  by  the  decomposition  of  urea. 

Then  arises  the  all-important  point,  "  Did  this  decomposition 
take  place  inside  or  outside  the  body  ?  "  If  outside,  and  only  after 
some  time,  it  represents  merely  a  normal  event  in  the  natural  history 
of  an  organic  substance  exposed  to  the  action  of  micro-organisms. 
If  inside,  or  within  say  an  hour  of  being  passed,  we  know  at  once 
that  either  the  bladder  or  renal  pelvis  (or  possibly  both)  is  in  a  very 
unhealthy  condition,  which,  if  not  speedily  improved,  is  likely  to 
lead  to  most  disastrous  consequences. 

Very  slight  attention  to  the  history  will  usually  suffice  to  clear 
up  the  point,  especially  if  the  question  be  asked,  "Are  you  sure 
the  urine  was  quite  clear  on  being  passed,  and  only  clouded  after 
standing  some  time  ?  "  Earthy  phosphates  without  ammonia,  pus, 
and  chyle,  are  the  only  fallacies  in  that  which  is  passed  cloudy, 
while  urates  will  be  the  only  fallacy  in  that  passed  clear,  and  each 
of  these  can  very  readily  be  differentiated  {vide  Chemical  and  Micro- 
scopical Tests). 

We  have  already  (p.  200)  discussed  the  diagnosis  of  kidney  or 
bladder  as  the  seat  of  the  trouble ;  and  for  relief  of  the  symptom 
(not  necessarily  of  the  disease)  local  injections  of  hot  boracic  lotion 
and  benzoate  of  ammonia  in  15  grain  doses  are,  in  my  experience, 
the  most  likely  means. 

URIC  ACID 

On  what  may  be  called  the  pathology  of  the  uric  acid  diathesis 
of  gout  and  of  gravel  and  nephrolithiasis,  so  much  has  been  written, 
so  many  theories  have  been  propounded,  and  in  their  turn  con- 
futed, that  it  seems  desirable  to  state  what  is  accepted  as  fact,  and 
separate  it  from  the  more  theoretical  and  disputed  points.  This 
we  may  do  in  parallel  columns,  so  as  to  draw  more  pointed  attention 
to  the  arguments. 


2IO 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Points  agreed  to  by  all,  and  accepted 
now  as  facts. 


Points  about  which  conflicting  theories 
and  statements  are  still  being  made. 


As  to  Uric  Acid  itself 


1.  That   uric   acid   is    one   of   the 

possible  products  of  the  de- 
composition of  the  complex 
nitrogenous  bodies  which 
exist  as  component  parts  of 
the  various  tissues  of  the 
body,  or  which  are  taken  into 
the  body  as  food  stuffs. 

2.  That  it  is   practically  the  only 

representative  of  nitrogenous 
waste  products  in  some  ani- 
mals, e.g.  birds  and  snakes. 

3.  That   it   is    present    in    certain 

small  amounts  in  the  urine  of 
every  healthy  human  being. 

4.  That   its    chemical  composition 

is  C.H,N,0„,  and  thus  con- 
tains  a  less  proportion  of  O 
than  urea  CH^NgO. 


Whether  the  food  {i.e.  that  part  of 
it  which  has  not  enteied,  or  will 
not  enter  into  the  molecular 
constitution  of  the  body  tissues) 
or  the  tissues  is  the  ultimate 
source  of  the  uric  acid  found  in 
the  urine  of  man. 

Whether  the  urates  of  snakes' 
urine,  etc.,  are  identical  in 
nature,  as  well  as  composition, 
with  those  of  human  urine. 

Whether  it  should  bear  any  con- 
stant proportion  to  the  urea,  and 
how  to  account  for  the  varying 
amounts  and  proportions  found. 

Its  exact  chemical  relationship  to 
urea,  i.e.  whether  in  the  human 
body  urea  can  be,  and  is  made 
from  uric  acid,  or  vice  versa ; 
or  whether  they  appear  side  by 
side,  as  it  were,  as  independent 
results  of  the  same  chemical 
processes  of  decomposition  ;  or 
whether  each  requires  a  separate 
series  of  reactions  for  its  pro- 
duction. 


As  to  Locality  of  Manufacture 


5.  That  it  is   manufactured  some- 

where in  the  body. 

6.  That  it  exists  in  the  blood  of  a 

patient  who  has  gout. 


Whether  in  the  liver,  the  tissues 
generally,  the  blood,  the  spleen, 
or  the  kidney. 

Whether  it  exists  in  the  blood  of  a 
healthy  individual. 


As  to  its  Clinical  Relationships 

7.   That  there  are  two  well-marked     Whether  these  two  diseases  must  be 
clinical  types  of  trouble  asso-         reckoned  as  primary  renal  affec- 


VI 


DISEASES  OF  THE  URINARY  ORGANS 


21  I 


Points  agreed  to  by  all,  and  accepted      Points  about  which  conflicting  theories 
now  as  facts.  and  statements  are  still  being  made. 


dated  with  uric  acid,  and 
that  these  two,  viz.  gout  and 
gravel,  may  and  do  occur 
separately. 

8.  That  heredity   plays  a  strong 

hand  in  the  production  of 
gout  or  gravel,  but  frequently 
alternations  of  the  two  in 
successive  generations  are 
met  with. 

9.  That     cartilage     and     fibrous 

tissue  do  become  infiltrated 
with  crystals  of  urate  of 
sodium. 


10.  That     per     pound     of     body 

weight  children  excrete  more 
uric  acid  than  adults. 

11.  That  gout  is  as  rare   in  chil- 

dren, compared  with  adults, 
as  stone  and  gravel  are 
common. 

12.  That    gout,     lead     poisoning, 

and  cirrhotic  kidney  occur 
in  the  relationship  of  pre- 
disponent,  excitant,  and  re- 
sultant in  a  far  larger  pro- 
portion than  mere  coincidence 
will  account  for. 

13.  That  diet  can   influence   gout 

and  gravel. 


tions,     or    whether    the    kidney 
suffers  only  secondarily. 


Whether  heredity  or  personal  en- 
vironment (in  its  widest  sense) 
is  the  stronger  factor. 


Whether  this  deposition  of  urate 
causes  the  painful  affection  of 
a  given  joint ; 

Whether  such  deposits  can  be  re- 
absorbed ; 

Whether  so-called  acute  gouty  arth- 
ritis is  not  really  acute  neuritis  ; 

Whether  the  deposition  is  a  cause 
or  consequence  of  local  necrosis. 

Whether  this  indicates  freer  ex- 
cretion only,  or  more  active 
formation  ;  in  fact,  its  meaning. 

The  essential  meaning  of  this. 


Which  of  the  three  is  predisponent, 
excitant,  or  resultant  ;  and 
whether  each  one  may  not  act 
in  any  capacity  at  times. 


Precisely  what  kind  of  diet  is  best 
for  gouty  patients. 


In  conclusion,  we  may  say  that  until  some  of  these  points  are 
authoritatively  settled  by  a  unanimous  agreement,  above  all,  the 
tissue  source,  and  seat  of  manufactory  of  uric  acid,  the  only 
practical  clinical  points  that  may  be  safely  deduced  are : — 


I.  That  uric  acid,   by  its  presence  in  the  body  in  excess,  is 


2  12  DIFFERENTIAL  DIAGNOSIS  chap. 

capable  of  working  mischief,  or  at  least  that  uric  acid  is  the  outward 
and  visible  sign  of  a  vital  metabolism  which  is  incompatible  with 
perfect  health. 

2.  That  if  we  find  it  in  excess  in  the  urine  or  body,  we  should 
recognise  its  potency  for  evil,  and  try  by  some  means  to  check  its 
production  in,  or  ingestion  into,  the  body. 

3.  That  as  regards  diet,  exercise,  and  even  drugs,  each  case 
must  be  treated  at  first  more  or  less  experimentally,  and  later  by 
the  light  of  such  knowledge  as  experience  of  the  individual  case 
may  give.  Sodium  salicylate  and  iodide,  with  moderation  in 
butcher's  meat  and  alcohol,  are  the  most  promising  measures  wdth 
which  to  commence  to  treat  an  unknown  patient. 

GLYCOSURIA 

With  regard  to  sugar  in  the  urine,  we  are  in  a  very  similar 
position  to  that  in  which  we  stand  in  the  case  of  uric  acid.  Many 
facts  require  explanation,  and  many  theories  have  been  brought 
forward  in  consequence.  Were  it  not  for  the  resolute  opposition  of 
Dr.  Pavy,  who  has  made  diabetes  the  special  object  of  a  life-long 
study,  we  might  say  that  there  is  complete  unanimity  in  the  views 
of  the  morbid  physiology  of  glycosuria.  A  similar  arrangement  to 
that  we  adopted  in  the  case  of  uric  acid  will  again  serve  to  empha- 
sise fact  and  theory. 

Fact.  Theory  or  Doubt. 

1.  That  sugar  does  occur  in  patho-     Whether   minute    traces    of  sugar 

logical  quantities  in  the  urine.  are   or  are  not    normal    in   the 

urine. 

2.  That  pathological  condition  may     Whether   glycosuria  and    diabetes 

be —  can  be  separated  as  two  distinct 

(a)  Temporary,  as  after  chloro-  conditions  ;  and  supposing  they 

form  and  experiment.  can,  what  is  the  real  and  precise 

(d)  Intermittent,    as    in   some  relationship   between   the  glyco- 

elderly  patients.  suria  of  diabetes  and  the  remain- 

(c)  Permanent  till  death,  as  in  ing  characteristic  symptoms    of 

many    cases    of  diabetes    in  that  disease. 

both  young  and  old. 

3.  That  in  many  cases,  especially 

of  Groups  (a)  and  (d),  it  is 
present  without  the  usual  as- 
sociated symptoms  of  actual 
diabetes   ever  occurring ;  but 


VI 


DISEASES  OF  THE  URINARY  ORGANS 


213 


Fact, 
in  many  commencing  as  appar- 
ently   simple    glycosuria     the 
more    severe     symptoms     do 
eventually  occur. 

4.  That  diet,  especially  with  regard 

to  carbohydrate  material,  does 
influence  very  markedly  almost 
every  case  of  glycosuria. 

5.  That  the  liver  contains  glycogen 

during  life  ;  that  this  glycogen 
is  derived  mainly  from  carbo- 
hydrate food  material ;  that 
after  death,  if  no  precautions 
are  taken,  the  liver  can  and 
will  convert  nearly  all  the 
glycogen  into  sugar. 


6.  That  in  many  cases  the  liver  is 
in  some  way  the  main  seat  of 
those  disturbances  in  metabol- 
ism which  result  in  glycosuria 
and  diabetes. 


Theory  or  Doubt. 


What  is  the  precise  connection 
between  food  and  sugar  in  the 
urine. 

It  is  on  this  point  that  Dr.  Pavy  is 
especially  insistent,  viz.  that  we 
have  no  proof  that  what  the 
liver  does  after  death  it  is  cap- 
able of  doing  during  life  ;  and 
hence  he  denies  the  more  com- 
monly accepted  view,  viz.  that 
the  liver  seizes  upon  all  carbo- 
hydrate material,  converts  it  into 
glycogen,  and  then  reconverts  it 
into  sugar,  according  to  the 
needs  of  the  body. 
The  real  nature  of  the  disturbance, 
whether  it  is — 
(a)  Merely  excessive  escape  due 

to  excessive  circulation  through 

the  blood  vessels. 
(^d)  Excessive     escape    due     to 

excessive  action  of  the  cells  of 

the  liver. 
(c)  Faulty    metabolism    of    the 

cells,  so    that   a  wrong  sort   of 

sugar   is   produced,  useless  for 

the  tissues. 
(^d)  Faulty    metabolism     in    not 

seizing  the  sugar  brought  to  the 

liver   and    converting    it    into 

glycogen. 


As  regaras  Morbid  Anatomy 


7.  That  in  some  cases  of  diabetes 
the  pancreas  is  found  diseased. 


\Vhether  the  disease  of  pancreas 
means  a  fifth  view  of  the  morbid 
physiology  of  diabetes,  equivalent 
to   a   diminished  destruction  of 


214  DIFFERENTIAL  DIAGNOSIS  chap. 

Fact.  Theory  or  Doubt. 

sugar  by  the   internal    secretion 
of  the  pancreas. 

8.  That   in  the    great    majority  of     Whether  there  are  not  such  micro- 

cases  of  diabetes  no  naked-eye  scopical  changes  in  the  medulla 

appearances  are  found  capable  as  might   explain   altered  meta- 

of  explaining  the  causation  of  bolic   power  on  the  part  of  the 

the  trouble.  liver 

9.  That  the  coma  from  which  the  The  precise  nature  of  the  substance 

great  majority  of  diabetics  die  which,    by   its   presence   in   the 

receives    no    adequate     post-         blood,  causes  the  coma, 
mortem  explanation. 

In  conclusion,  whatever  views  maybe  held  on  the  disputed 
points  in  the  pathology  of  diabetes,  the  diagnostic  points  are  very 
simple,  for  the  facts  are  so  strong  that  no  objection  can  be  raised 
to  the  statement,  "  If  sugar  be  constantly  present  in  the  urine — for 
a  longer  period  than,  say,  twenty-four  hours — in  sufficient  quantity 
to  be  detected  by  thirty  seconds'  boiling  with  Fehling's  solution, 
there  is  a  serious  pathological  condition  present  which  requires  the 
careful  attention  of  the  medical  man."  (For  one  or  two  further 
remarks  of  a  clinical  character,  vide  Diabetes.) 


UREMIA 

This  term  was  originally  invented  to  express  a  series  of  symp- 
toms due  to  a  supposed  excess  of  urea  in  the  blood ;  we  now  use 
it  in  a  wider  sense,  or  rather  in  a  different  sense,  to  cover  the 
symptoms  produced  by  the  retention  within  the  blood  (or  tissues) 
of  waste  products  in  general,  which  should  be  eliminated  with  the 
urine.  Thus  far  everyone  is  agreed,  but  when  the  further  question  is 
put — "What  is,  or  are,  the  particular  waste  products  ?" — no  answer  is 
forthcoming  except  negative  ones.  It  is  not  urea,  nor  uric  acid,  nor 
potassium  ^  {vide  footnote),  nor  water,  nor  inorganic  salts,  nor  kreatin, 
in  fact,  it  is  not  any  single  ingredient  of  the  urine  which  has 
hitherto  been  isolated.^ 

The  nearest  probability  would  be  a  suggestion  that  each  organ 
and  tissue  is  responsible  for  its  own  share  in  the  production  of  the 
total  phenomenon ;  the  special  waste  products  of  each  (whatever 

^  The  latest  view  of  all  is  that  uraemia  is  due  to  retention  of  potassium  salts. 
2  All  these  points   are   conclusively  proved   by   M.    Bouchard's   work  on   auto- 
intoxication, translated  by  Oliver. 


VI  DISEASES  OF  THE  URINARY  ORGANS  215 

their    nature)    acting    as    a   hindrance   to   the   proper   functioning 
of  itself  (and  probably  to  a  varying  extent  of  other  organs). 

Diagnosis  of  Uraemia 

To  associate  its  occurrence  into  the  following  groups  will,  I  think, 
best  conduce  to  its  diagnosis. 

Group  A. — Acute  and  severe,  probably,  though  not  certainly, 
producing  a  rapidly  fatal  termination  to — 

(i)  A  known  and  watched  case  of  kidney  disease. 

(2)  A  known  and  watched  case  of  other  disease  in  which 
urinary  symptoms  are  now,  or  have  been  all  along,  pro- 
minent, e.g.  cardiac  disease  with  suppression. 

(3)  An  unknown  and  unwatched  case  of  sudden  illness 
of  convulsive  or  comatose  type  in  a  patient  previously  sup- 
posed to  be  in  good  health. 

Group  B. — So-called  chronic  uraemia,  in  which  the  symptoms, 
though  possibly  acute  enough  and  severe  enough  in  them- 
selves, pass  off  or  yield  to  appropriate  treatment,  and 
recur  again  and  again  over  months  or,  it  may  be,  years. 

Of  Group  A,  Nos.  (i)  and  (2),  I  have  nothing  to  say  beyond 
what  will  be  found  in  every  text-book.  The  symptoms  are  fairly 
uniform,  starting  with  a  violent  headache  or  sudden  blindness,  or 
acute  vomiting,  or  diarrhoea,  and  rapidly  passing  into  convulsions, 
coma,  and  death  ;  or  it  may  be  sudden  convulsions  or  coma,  passing 
into  death.  In  any  case,  the  only  difficulty  in  diagnosis  rests  in 
bearing  in  mind  the  great  possibility,  or  rather  probability,  of  uraemia 
supervening  in  a  certain  class  of  diseases. 

Group  A,  No.  (3),  presents  great  difficulty  in  diagnosis,  but  as 
the  condition  is  one  presenting  great  likeness  to  alcoholic  and  other 
poisoning  and  cerebral  disease,  it  is  fully  discussed  under  the 
heading  with  which  the  lay  press  has  made  us  unhappily  familiar, 
viz.  "  Drunk  or  Dying"  (^.z^.  Chap.  IX.). 

Group  B  is  the  group  of  chronic  uraemias  to  which  I  wish  to 
draw  special  attention,  as  I  feel  convinced  that  many  cases  of  it 
pass  unnoticed  or  called  by  another  name,  for  the  simple  reason 
that  students  are  so  accustomed  to  the  idea  of  the  acute,  rapidly- 
fatal  symptoms  as  the  only  form  of  uremia,  that  they  overlook  the 
"  fringes  "  (to  borrow  Dr.  Goodhart's  phrase)  of  the  condition. 

The  late  Sir  Andrew  Clark,  I  believe  it  was,  who  coined  the 
expression,  "renal  inadequacy,"  and  this  is   the  condition  which 


2i6  DIFFERENTIAL  DIAGNOSIS  chap. 

underlies  and  explains  many  or  all  of  the  following  symptoms  so 
commonly  found  in  elderly,  and  even  young  people,  whose  urine  is 
habitually  only  just  within  the  physiological  limits  of  the  product 
quantity  x  specific  gravity.  I  refer  to  attacks  of  indigestion  or 
diarrhoea  without  obvious  dietetic  irregularities,  to  attacks  of  deaf- 
ness, giddiness,  etc.,  swimming  in  the  head,  so  often  thought  of  as 
precursors  of  apoplexy ;  to  severe  headaches  of  a  prostrating  char- 
acter, to  transitory  parsesthesise,  felt  in  parts  of  the  body  or  limbs, 
or  pareses  of  the  same  parts ;  to  a  frequent  feeling  of  malaise  and 
general  despondency ;  nay,  I  will  go  farther  and  say,  without  fear 
of  contradiction,  that  this  same  renal  inadequacy  is  at  the  bottom 
of  the  known  experience  that  operations  on  kidney  subjects  do 
badly,  that  it  explains  the  liability  of  many  patients  to  chronic 
bronchitis  and  emphysema,  pneumonia,  pleurisy,  pericarditis,  peri- 
tonitis (whether  serous  or  suppurative),  cardiac  failure ;  that,  in  fact, 
it  is  the  real  meaning  of  those  so-called  intercurrent  affections,  not 
excluding  acute  nephritis,  which  so  frequently  close  the  scene  in 
cirrhotic  kidney.  It  is  the  circulation  of  imperfectly  depurated 
blood  that  renders  all  these  organs  so  liable  to  break  down  with 
acute  inflammatory  mischief.  This  persistent  and  steady,  though 
it  may  be  very  slow,  accumulation  of  waste  material  is  as  essenti- 
ally chronic  uraemia  as  is  the  rapid  accumulation  acute  uraemia. 

As  far  then  as  diagnosis  is  concerned,  the  rule  may  be  emphatic- 
ally laid  down  that  in  all  diseases  of  the  above  character  the  urine 
should  be  systematically  examined  every  day,  and  especially  is  this 
necessary  if  the  patient  is  over  forty.  An  elaborate  analysis  is  not 
required,  but  the  total  quantity  and  specific  gravity  are  essential  for 
a  correct  appreciation  of  the  output  of  waste  organic  material. 

Suppression  v.  Retention 

If  there  is  reliable  information  that  very  little  or  no  urine  has 
been  passed,  say  for  twenty-four  hours,  these  two  conditions  cannot 
easily  be  confused.  An  abdominal  examination  must  be  made  :  this 
will  or  will  not  reveal  the  presence  of  the  distended  bladder ;  in  either 
case,  the  catheter  must  then  be  passed  to  relieve  the  symptom  if 
the  bladder  be  distended,  or  to  prove  the  absence  of  urine.  The 
only  exceptions  to  the  whole  of  the  above  rule  and  treatment  are 
occasional  cases  of  pure  hysteria,  in  which  the  pleasures  of  instru- 
mentation overcome  the  discomforts  of  a  full  bladder.  Such  cases 
require  great  tact  in  handling,  but  offer  no  diagnostic  difficulties. 

Difficulties  in  diagnosing  retention  may  occur  when  overflow  is 


VI  DISEASES  OF  THE  URINARY  ORGANS  217 

also  present,  or  when  micturition  is  alleged  to  be  natural.  The 
former  occurs  commonly  enough  in  puerperal  cases  (I  have  known 
a  distended  bladder  under  these  circumstances  called  acute 
metritis),  and  should  also  always  be  held  in  mind  when  diseases  of 
cord  and  brain  are  being  treated.  It  will,  of  course,  be  usually 
associated  with  local  pain,  directing  attention  to  the  bladder,  but  if 
unnatural  anaesthesia  be  present,  a  distended  bladder  requires  to  be 
borne  in  mind  and  looked  for.  The  latter  condition,  i.e.  disten- 
sion, with  alleged  natural  micturition,  is  practically  confined  to 
elderly  male  patients  with  prostatic  trouble.  It  is  apt  to  be  very 
misleading,  owing  to  the  gradual  acquirement  of  a  condition  of 
tolerance  for  increasing  quantities  of  residual  urine.  I  have  seen 
a  patient  with  bladder  distended  to  the  umbilicus  who  assured  me 
that  he  could  not  pass  me  any  water  because  he  had  micturated 
just  before  his  visit.  He  was  totally  unconscious  of  his  urinary 
condition,  which  proved  fatal  within  a  few  weeks. 

The  causes  of  suppression  of  urine,  i.e.  of  anuria  with  empty 
bladder,  may  thus  be  tabulated  : — 

A.  Mechanical     Stone  {vide  Stone  in  Kidney). 

blocking      of     Carcinoma, — previous  haemorrhage,  and  tumour, 
ureter,  due  to        Tubercle, — previous  pus,  and  haemorrhage. 
Blood  clot, — previous  hsemorrhage. 

B.  So  -  called    func-     Heart  failure,  or  other  form  of  venous  back  pres- 

tional      from  sure, — cardiac  bruits,  with  obvious  back  pres- 

kidney     condi-  sure,  or  swelling  and  tumour  of  abdomen, 

tions,  due  to  Active  irritation,  such  as  that  caused  by  drugs, — 

history  of  taking  a  drug. 
Actual  inflammation, — other  signs  of  acute  neph- 
ritis, ansmia,  piiffiness  of  eyelids,  etc. 

The  causes  of  retention,   i.e.   anuria,  \^nth  a  full  bladder,  are 
again  : — 

A.  Mechanical     ob-     Position  diagnosed  by  the  catheter ;  uterine  con- 

struction, dition  also  to  be  thought  of. 

B.  Functional   inca-     Cause  to  be  sought  in  the  nervous  system,  or  in 

pacity     of     ex-  previous  history  of  over-distension. 


pulsion. 


BRIGHT'S  DISEASE 


Before  saying  anything  as  to  the  diagnosis  of  the  various  forms 
of  Bright's  disease,  it  would  be  well  to  define  the  term.     There  are 


2i8  DIFFERENTIAL  DIAGNOSIS  chap. 

then  four  fairly  well-marked  types  of  it  from  a  clinical  point  of 
view : — 

1.  Acute  nephritis. — The  word  "acute  "  as  used  in  medicine  sadly 

needs  accurate  definition :  sometimes  it  has  mainly  refer- 
ence to  time,  i.e.  with  well-marked  definite  onset,  without 
reference  to  the  severity  of  the  symptoms ;  sometimes  it 
is  used  to  denote  more  the  intensity  of  the  symptoms,  i.e. 
in  our  present  illustration  the  smoky  or  bloody  urine. 
Acute  nephritis  is  practically  always  due  to  a  toxaemia,  i.e. 
to  the  efforts  of  the  kidney  to  secrete  from  the  blood  some 
substance  which  actively  irritates  the  kidney  cells  in  the 
process  of  separation,  e.g.  the  poison  of  scarlet  fever,  diph- 
theria, or  substances  produced  in  the  blood  by  a  condition 
popularly  known  as  a  chill. 

2.  Consecutive  Nephritis. — This  is  a  convenient  term  to  desig- 

nate the  condition  of  a  patient  who  has  (a)  at  some  pre- 
vious period  suffered  from  acute  nephritis,  and  has  never 
since  been  quite  free  from  urinary  changes ;  {b)  has  drifted 
into  a  condition  of  renal  disease  without  m^arked  onset,  as 
in  some  of  the  scarlet  fever  cases  not  under  careful  obser- 
vation, and  (?)  some  cases  of  earlier  albuminuria  simplex 
{q.v.)',  or  (c)  has  his  kidneys  irritated  by  local  conditions, 
such  as  stone,  simple  blocking  or  kinking  of  the  ureter,  and 
all  forms  of  surgical  kidney.  The  group  is  obviously  a 
mixed  one,  and  most  of  the  cases  will  in  practice  naturally 
have  a  specific  name  applied  to  them.,  but  they  all  have 
one  point  in  common,  that  if  they  last  long  enough,  and  if 
the  essential  kidney  structure  does  not  wholly  disappear, 
they  lead  eventually  to  the  form  of  granular  kidney  known 
as  the  small  white  or  secondarily  contracted  kidney. 

3.  The  Cirrhotic  Kidney,  of  which  one  type  is  the  later  stages  of 

Group  2,  and  the  other  is  the  small,  red,  granular  kidney 
so  frequently  associated  with  degenerate  vessels  and  large 
heart,  with  age  over  forty,  with  gout,  and  with  lead  poison- 
ing. It  must  be  ever  constantly  borne  in  mind  that  either 
type  may  at  any  moment  blaze  up  into  an  acute  nephritis  ; 
in  fact,  this  is  the  commonest  event  in  their  course. 

4.  Large  White  Kidney. — A  disease  just  as  much  sui  generis  and 

absolutely  independent  of  other  kidney  trouble,  as  is,  say, 
typhoid  fever  or  cerebral  glioma.  It  has  a  rapid  history, 
with  an   invariably  fatal   termination  within  three  to   six 


VI  DISEASES  OF  THE  URINARY  ORGANS  219 

months.  It  never  starts  from,  or  turns  into  anything  else, 
and  may  be  called  acute  degeneration  (fatty  changes  pre- 
ponderating) of  the  kidneys. 

As  to  their  clinical  course  and  main  danger  signals,  these  four 
types  may  be  briefly  epitomised  as  follows : — 

Acute  Nephritis  threatens  life  chiefly  in  its  early  days,  and  that 
almost  entirely  by  suppression  and  acute  uraemia.  If  this 
stage  be  passed,  we  may  then  say  that  the  lapse  of  nine  to 
twelve  months  will  show  whether  the  case  will  end  in 
complete  recovery  or  will  drift  into  one  of  consecutive 
nephritis. 

Consecutive  Nephritis. — Of  the  sub-groups  (a)  and  {b)  the  dura- 
tion is  commonly  one  of  years,  though  of  course  often  much 
less,  in  which  the  patient  shows  important  and  marked 
changes  in  the  urine  (albumen  and  casts).  The  main 
clinical  features  of  the  condition  will  be  occasional  puffiness 
of  the  face,  especially  in  the  lower  eyelid,  general  flabbiness 
and  malaise,  and,  above  all,  anaemia,  to  which  I  would  draw 
special  attention  as  the  main  element  in  the  disease.  So 
long  as  the  patient  keeps  a  fair  colour,  or  the  anaemia  does 
not  advance,  so  long  are  there  good  hopes  of  prolonging 
life ;  but  with  the  advance  of  blood  impoverishment  must 
come  increased  anxiety  as  to  the  advent  of  severe  ur^emic 
symptoms,  of  which  the  anaemia  is  the  advance  guard  and 
warning  beacon.  Of  the  sub-group  (c)  the  dangers  are 
much  the  same,  for  they  essentially  depend  upon  disorgan- 
isation of  the  kidney,  but  the  prognosis  has  two  elements  in 
it — first,  "  How  far  has  the  destruction  of  the  kidney  sub- 
stance progressed  before  surgical  measures  are  adopted?"  and, 
secondly,  "  Is  the  primary  cause  of  the  trouble  one  which  can 
be  permanently  cured  by  these  surgical  measures  if  they  are 
applied  ?  " 

Cirrhotic  Kid?iey. — The  first  group  is  sufficiently  sketched  under 
Consecutive  Nephritis,  of  which,  indeed,  it  forms  merely 
the  concluding  chapters.  The  other  type  of  cirrhotic  kidney, 
i.e.  the  independent  form  w^ithout  previous  history  of  urinary 
trouble,  can  scarcely  be  said  to  have  a  clinical  course.  It 
begins  so  insidiously  that  it  hardly  comes  under  notice  until 
the  thickened  arteries  and  the  hypertrophied  (probably  also 
dilating,  vide  IMorbus  Cordis)  heart  are  discovered  on  the 
routine  examination  of  a  patient  who  comes  before  us  struck 


2  20  DIFFERENTIAL  DIAGNOSIS  chap. 

down  by  apoplexy,  or  affected  with  one  of  the  diseases 
already  mentioned  as  essentially  ursemic  {<j.v^  in  nature. 
The  last  scene  is  always  either  of  this  nature,  or  else  a  simple 
uncomplicated  uraemia,  which  in  turn  is  brought  about  either 
by  an  absolutely  too  great  organic  destruction  of  kidney 
tissue,  or  by  an  acute  nephritis,  which  renders  a  still  organi- 
cally adequate  kidney  functionally  inadequate. 
Large  White  Kidney. — This  has  for  years  been  described  as  a 
form  of  chronic  Bright's  disease,  and  included  amongst  those 
cases  for  which  I  have  adopted  the  term  Consecutive  Ne- 
phritis. A  comparison  of  the  accounts  of  writers  thus 
describing  it,  combined  with  my  own  post  -  mortem  ex- 
perience, have  compelled  me  to  claim  for  it  a  course  which 
is,  at  any  rate,  acute  enough  when  measured  by  time,  and 
also  by  urinary  symptoms.  If  at  the  post-mortem  the 
kidneys  (not  being  amyloid)  are  very  white,  large  (say  to- 
gether over  14  ozs.),  and  especially  if  the  capsule  strips 
easily  without  tearing  the  substance  at  all,  but  leaving  a 
perfectly  smooth  surface  to  the  organ,  then  the  clinical 
history  shows  only  a  four  to  six  months'  duration  of  illness 
at  the  outside,  and  frequently  one  of  only  six  to  ten  weeks. 
The  main  features  of  the  illness  are  always  the  same,  viz. 
very  marked  anaemia,  excessive  oedema,  especially  of  thighs 
and  legs  (large  white  legs,  large  white  kidney,  is  a  patho- 
logical proverb),  and  a  urine  such  as  is  tabulated  below; 
and  these  serve  to  distinguish  this  affection  during  life  from 
any  other  except  the  absolutely  final  chapter  of  a  con- 
secutive nephritis  which,  if  diagnosis  is  required,  can  be 
readily  recognised  by  its  commencement.  The  invariable 
ending  of  large  white  kidney  is  acute  uraemia. 

This  brief  sketch  shows  plainly  enough  that  all  forms  of  Bright's 
disease  have  a  distinct  tendency  to  drift  into  serious  uraemia,  the 
only  exception  being  some  cases  in  Group  {c)  of  Consecutive  or 
Secondary  Nephritis,  provided  that  the  local  cause  of  the  nephritis 
is  one  which  is  capable  of  complete  removal  by  surgical  aid,  and 
also  provided  that  the  condition  is  ascertained  and  removed  before 
extensive,  serious,  and  progressive  destruction  of  renal  tissue  has 
been  set  up.  Our  first  object,  then,  when  a  patient  presents  himself 
with  a  condition  of  urine  indicating  damage  to  the  kidney,  is  to 
ascertain  whether  such  a  removable  cause  is  present  or  not.  This 
will,  however,  be  more  conveniently  discussed  in  the  next  section; 


VI 


DISEASES  OF  THE  URINARY  ORGANS  221 


in  the  present  one  we  will  discuss  the  diagnosis  of  the  uncompli- 
cated forms  of  Bright's  disease. 

A  slight  inquiry  into  the  previous  health  and  urinary  history  of 
the  patient,  combined  with  a  knowledge  of  the  onset  of  the  present 
illness,  will  speedily  separate — 


Simple  chronic  nephritis 
on  the  one  J       of  either  type  without 
hand  from  |       the    acute    exacerba- 
tion. 


Primary  acute  nephritis 
Secondary  acute  nephritis  (as  an 

incident  in  chronic) 
Large  white  kidney 

They  will  also  separate  very  distinctly  the  primary  from  the 
secondary  acute  nephritis.  The  profound  anaemia  of  very  rapid 
onset,  combined  with  the  extreme  oedema,  are  usually  striking 
enough  to  separate  large  white  kidney  from  either  form  of  acute 
nephritis.  Should  these  general  indications  not  be  sufficient,  the 
condition  of  the  urine  tabulated  below  will  settle  the  matter.  In 
the  more  chronic  conditions  a  keen  eye  to  note  progressive  asthenia 
and  anaemia,  and  a  careful  analysis  of  the  urine  from  day  to  day  for 
a  short  period,  are  the  important  requisites  for  estimating  the  stage 
which  the  sufferer  has  reached  on  his  road  to  uraemia. 

Urine  in  Bright's  Disease  (and  in  Lardaceous  Kidney) 


Acute. 

Quantity — 
Much   dimin- 
ished, some- 
times to   sup- 
pression. 


Blood- — 
Invariably  pre- 
sent in  visible 
amount ; 
smoky      or 
bloody. 
Sp.  Gravity — 
Increased. 


Consecutive  and 
Cirrhotic.-^ 

Increasing  in 
proportion  to 
the  change 
towards  cir- 
rhosis; di- 
minishing at 
the  last. 

Absent  without 
acute  exacer- 
bation. 


Diminished, 
even  if  quan- 
tity diminished. 


Large  White. 

Much  dimin- 
ished, but  not 
to  suppres- 
sion. 


Lardaceous. 

Usually  in- 
creased, but 
not  always. 


Only  detected 
by  the  micro- 
scope. 


Probably  below 
average. 


Absent. 


About  normal. 


^  These  changes  are  independent  of  pus,  blood,  crystals,  etc, ,  produced  by  any 
possible  local  trouble,  and  refer  to  the  nephritis  only. 


222 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Acute. 

Albumen — 
Much,  often 
nearly  solid, 
probably  col- 
o  u  r e  d  by 
blood. 


Casts — 
Blood,    epithel- 
ial,   etc.   {vide 
under  Casts). 


Colour — 
Dark,     concen- 
trated, smoky, 
or  red. 


Consecutive  and 
Cirrhotic. 


Large  White. 


Lardaceous. 


Variable,     but     From     half     to     Variable,    but 


solid,  always 
much,  not 
coloured  by 
blood. 


always  con- 
siderable, i.e. 
one  -  fifth  or 
more. 


generally  not 
more  than  a 
trace  unless 
serious  con- 
dition coming 
on,  often  quite 
absent. 


Veryfew,hyaline     Plentiful,     some     Sometimes 


or  fatty,  more 
numerous  if 
acute  exacer- 
bation. 


Very  light,  ex- 
cept in  acute 
exacerbation. 


epithelial,  but 
mostly  fatty 
and  hyaline. 


Natural, 


none,  may  be 
many,  and 
are  said  some- 
times to  show 
lar  daceous 
changes. 

Usually    lighter 
than  natural. 


In  the  daily  analysis  the  points  of  especial  importance  are  the 
total  quantity  and  the  specific  gravity,  the  relative  abundance  of 
casts  and  other  debris.  The  former  giving  us  the  product  of 
specific  gravity  by  quantity,  which  is  a  rough  indication  of  the 
output  of  waste  material ;  the  latter  giving  a  fair  estimate  of  the 
activity  of  renal  destruction.  In  comparison  with  these  two  in- 
dications the  amount  of  albumen  sinks  into  insignificance. 

We  may  now  discuss  those  conditions  of  the  urinary  tract  which 
are  liable  to  cause  by  their  continuance  a  consecutive  or  secondary 
nephritis,  or  to  be  mistaken  for  Bright's  disease  owing  to  certain 
urinary  changes  produced  by  them.  They  may  be  enumerated  as 
follows : — 


Group  I. 


Preputial  or  urethral  stricture,  prostatic   enlargement  or 
other  affection  of  the  prostate,  stone  in  the  bladder,  etc., 
fact,    peripheral    obstacles   to    the    escape   of  urine 


m 


from  the  bladder,  as  well  as  certain  ulcers  and  growths 
of  the  bladder  itself. 
Group  2.  Similar  affections  of  the  ureter  arising  in  its  structure,  or 
affecting  it  from  without. 


VI  DISEASES  OF  THE  URINARY  ORGANS  223 

Group  3.   Affections  of  the  pelvis  or  substance  of  the  kidney — 

Stone.  Hydronephrosis  from  un- 

Tubercle.  known  causes. 

Mahgnant  growths.  Hydatids  and  other  rarer 

Undue  mobihty.  affections. 

The  differential  diagnosis  of  the  members  of  Group  i  is  essenti- 
ally surgical,  and  does  not  ordinarily  present  much  difficulty,  as  the 
prepuce,  penis,  urethra,  prostate,  and  bladder  are  open  to  direct 
examination  and  investigation  by  the  eye,  finger,  bougie,  and  cysto- 
scope.  From  the  urgency  of  their  symptoms  they  compel  surgical 
interference,  whatever  be  the  functional  capacity  of  the  kidneys  as 
a  factor  in  prognosis,  so  that  the  possibly  associated  Bright's  disease 
may  be  temporarily  left  out  of  the  question. 

The  presence  of  a  member  of  Group  2  can  only  be  surmised 
by  the  positive  fact  of  the  presence  of  pathological  urine,  or  a 
tumour  in  the  abdomen,  combined  with  the  negative  fact  of  the 
absence  of  disease  from  the  bladder  down  to  the  prepuce,  leaving 
us  to  infer  that  the  trouble  is  situated  in  ureter  or  kidney.  The 
only  cases  in  which,  then,  the  ureter  would  be  suspected  w^ould  be 
the  disappearance  of  a  known  collection  of  pus  with  profuse  pyuria 
appearing,  or  the  discovery  of  a  hydronephrotic  tumour.  In  practice, 
however,  it  is  impossible  to  distinguish  even  these  cases  from 
trouble  at  the  hilum  of  the  kidney. 

The  third  group,  viz.  affection  of  the  pelvis  or  substance  of  the 
kidney  itself,  requires  more  detailed  examination ;  and  we  may 
commence  with  the  three  more  ordinary  affections,  viz.  stone, 
tubercle,  and  malignant  disease.  Though  not  absolutely  germiane 
to  the  subject  of  differential  diagnosis,  there  is  one  clinical  fact 
that,  on  account  of  its  tremendous  importance,  cannot  be  omitted, 
viz.  that  any  one  of  these  three  may — and  not  as  a  mere  pathological 
curiosity,  but  even  w'ith  some  little  frequency — be  present  without 
causing  either  a  pathological  condition  of  the  urine,  or  a  tumour  in 
the  abdomen ;  not  only  so,  but  the  patient  may  even  die  of  obscure 
symptoms,  probably  ursemic  in  nature,  without  the  kidney  being 
suspected,  until  a  post-mortem  examination  reveals  the  most  exten- 
sive destruction  of  one  organ,  or  even  of  both  of  them. 

We  are,  however,  now  assuming  that  some  or  all  of  the  following 
local  indications  are  present — blood,  pus,  albumen,  casts,  and  other 
deposits  in  the  urine,  pain,  either  colicky  or  persistent,  tumour  in 
the  abdomen;  and  we  have  to  consider,  from  their  various  com- 
binations, which  is  the  most  likely  lesion  present : — 


224  DIFFERENTIAL  DIAGNOSIS  chap. 

The  following  table  shows  the  chief  diagnostic  indications : — 


Stone. 

Tubercle. 

Carcinoma. 

Quantity  of 

During  colic  often 

Usually  unaltered, 

Also    usually   un- 

urine. 

suppressed, 

if  any  effect  it 

altered. 

otherwise      un- 

is diminished. 

altered    or    in- 

creased. 

Blood. 

Moderately      fre- 

Often    a     smart 

Haemorrhage   not 

quent,  but  usu- 

haemorrhage. 

infrequent,   but 

ally  not  severe, 

less    frequently 

more   likely   to 

and  quite  inter- 

repeated    than 

be  a  continual 

mittent. 

in    other    con- 

oozing,    there- 

ditions. 

fore  blood 
pretty  con- 
stantly present. 

Pus. 

Not    common    in 

Often    very    pro- 

Not profuse  as  a 

any      quantity. 

fuse  indeed,  and 

rule  ;  if  present 

unless  urine  is 

that  with  quite 

in     quantity. 

alkaline       and 

acid  urine,  and 

severe  features 

ammoniacal. 

without    neces- 

are usually  pre- 

sarily      severe 

sent. 

symptoms. 

Albumen. 

Unless  associated 

Practically      only 

In   proportion    to 

with      either 

in      proportion 

pus  and  blood. 

blood  or  pus  is 

to  pus. 

and       possibly 

really  an   indi- 

some  nephritis. 

ca  t  i  on        of 

but  obviously  of 

Bright's,      and, 

no  real  import. 

as     such,     has 

much       impor- 

tance. 

Other     de- 

Uric acid,  if  any, 

Tubercle      bacilli 

Fragments      of 

posit. 

and      minute 

in  the  pus. 

growth      possi- 

stones. 

bly,  but  they 
are  rare. 

Pain. 

Often  none;  some- 

Dull   ache    most 

Dull     ache     or 

times     a     con- 

usually,   if  any 

acute      local 

stant  dull  ache, 

at  all,  but  ordi- 

pain ;      typical 

but   renal  colic 

nary  attacks  of 

colic  very  rare. 

the       typical 

colic     not    un- 

form ;       active 

known. 

jolting     almost 

VI 


DISEASES  OF  THE  URINARY  ORGANS 


225 


Tumour. 


Stone. 

invariably 
causes  exacer- 
bation. 
Of  stone  per  se 
never  present, 
but  may  be  a 
hydronephro- 
sis. 


Tubercle. 


Kidney  often 
large,  may  be 
felt  as  a  tumour; 
kidney  fre- 
quently hydro- 
nephrotic. 


Carcinoma. 


Tumour  if  felt 
more  irregular, 
much  less  like 
a  kidney  in 
shape  ;  may 
bulge  into  loin. 


This  table  will  well  bear  a  few  clinical  remarks.  The  most 
important  practical  general  statement,  and  the  one  most  humiliating 
to  medical  science,  is,  that  after  all  points  have  been  fully  con- 
sidered, the  diagnosis  will  sometimes  still  remain  in  doubt ;  gravel, 
bacilli,  and  fragments  of  growth,  the  three  almost  pathognomonic 
signs,  may  each  and  all  fail  us,  and  we  have  to  call  to  our  aid 
exploratory  surgery  for  the  relief  of  symptoms  serious  in  themselves, 
but  of  unknown  causation. 

Apart  from  these  doubtful  cases  of  impossible  separation,  we 
may  say  a  few  words  on  the  individual  conditions. 


Stone  in  the  Kidney 


It  has  already  been  mentioned  that  the  kidney  may  be  entirely 
disorganised  by  stone,  without  its  presence  being  suspected  from 
any  active  phenomena ;  but  we  are  now  dealing  with  an  analysis  of 
actual  symptoms,  amongst  which  renal  colic  (intermittent  in  type, 
made  worse  by  jolting  movements,  passing  to  the  testicle)  and 
intermittent  hsematuria  (almost  constantly  associated  with  colic) 
are  the  two  most  suggestive.  It  is  worth  bearing  in  mind  (in  the 
presence  of  colic  with  suppression  of  urine)  that  in  a  first  attack  of 
colic  from  renal  calculus  both  ureters  are  never  blocked  at  the  same 
time,  and  we  therefore  have  strong  hope  under  such  circumstances 
of  a  first  attack  that  the  flow  of  urine  will  be  re-established  wdthin 
a  short  time,  even  if  the  stone  be  not  passed ;  but  if  the  patient  be 
suffering  from  an  attack  of  renal  colic,  and  there  be  a  history  of 
similar  previous  trouble,  especially  if  of  great  severity,  then  the 
probability  of  both  ureters  being  blocked  is  considerably  increased, 
and  our  anxiety  for  early  mechanical  relief  proportionately  acute. 
This  is  especially  the  case  when  we  remember  that  uraemia  from 

0 


226  DIFFERENTIAL  DIAGNOSIS  chap. 

obstructed  ureters  is  very  insidious  —  a  little  increased  general 
weakness  in  the  patient,  an  occasional  twitch  in  one  or  two  muscles, 
no  obvious  ingravescence  of  these  till  quite  suddenly  drowsiness 
and  fatal  coma  set  in. 

Tuberculosis  of  Kidney 

This  is  most  commonly  a  secondary  affection,  or  rather  it  would 
be  more  accurate  to  say  the  kidney — if  tubercular — is  rarely  the 
only  tubercular  focus  in  the  body. 

1.  It  may  be  part  of  a  miliary  attack,  in  which  case  it  will  only 
be  recognised  on  post-mortem  examination  j  it  possesses  no  clinical 
diagnostic  interest. 

2.  It  may  be  associated  with  obvious  tubercle  of  the  lung. 
Here  it  will  be  recognised,  if  at  all,  by  aching  pain  in  the  loins  and 
urinary  alterations  —  albuminuria,  haematuria,  or  pyuria  {q.v.).  In 
such  a  case  its  recognition  is  more  important  from  a  prognostic 
than  from  any  other  point  of  view,  for  advanced  phthisis  is  a 
strong  contra-indication  to  any  serious  operative  interference,  and 
I  have  never  seen  cured,  as  opposed  to  merely  quiescent,  tubercle 
of  the  kidney. 

3.  Even  when  confined  to  the  genito-urinary  tract,  the  kidney 
may  be  only  secondarily  implicated  by  extension  from  the  bladder. 
Here,  frequent  micturition,  pain  in  penis,  and  pyuria  will  have 
attracted  attention,  and  the  cystoscope  will  have  assured  us  that  the 
bladder  at  any  rate  is  implicated ;  renal  casts  and  cells  found  by  the 
microscope,  and  a  continuance  of  pyuria  after  the  bladder  trouble 
has  healed,  will  be  the  chief  indications  that  the  kidney  itself  is 
also  implicated.  Lastly,  should  the  case  be  one  of  genuine  primary 
tuberculosis  of  the  kidney,  the  diagnosis  will  be  formed  somewhat  as 
follows  :  an  aching  or  even  an  acute  pain  in  the  loin  will  have  led 
the  patient  to  seek  for  advice ;  inquiry  will  then  be  specially  made 
into  the  urinary  function ;  or,  failing  any  special  complaint,  the 
routine  examination  of  the  urine  will  have  led  us  in  the  same 
direction,  viz.  to  suspect  the  kidney.  Inquiry  and  examination  will 
then  have  revealed  some  features  of  great  probability  in  diagnosis 
— pain,  tenderness,  hsematuria,  pyuria,  etc.  Lastly,  to  complete 
the  diagnosis,  bacteriological  examination  of  the  urine,  or  its 
deposit,  will  frequently  enough  be  necessary,  and  in  suspicious  cases 
cannot  be  omitted. 

N'.B. — One  ureter  may  be  completely  blocked  by  causation,  so 
that   the   urine  may  be  natural   in   quality,  and  possibly  also  in 


VI  DISEASES  OF  THE  URINARY  ORGANS  227 

quantity ;  hence  we  must  not  too  hastily  acquit  the  kidney  if  the 
previous  history  or  local  indications  point  strongly  in  that  direction. 


Malignant  Disease  of  Kidney 

Like  neoplasms  elsewhere,  may  be  primary  or  secondary.  If  the 
latter,  diagnosis  is  very  much  a  matter  of  indifference  in  clinical 
work  ;  the  points  are  identical  with  those  of  a  primary  case,  clarified 
considerably  by  the  presence  of  the  original  growth.  Primary 
malignant  disease — sarcomata  are  tolerably  common  in  children — 
can  only  be  recognised  by  a  process  of  exclusion ;  the  hsematuria, 
which  is  far  and  away  the  commonest  symptom,  being  common  to 
at  least  three  renal  affections,  whose  differential  diagnosis  has  been 
considered  above.  Unless,  then,  we  can  find  a  tumour  in  the 
loin  or  abdomen,  or  at  least  some  gross  irregularity  in  the  outline 
of  the  kidney,  stone  and  tubercle  must  be  first  excluded.  The 
cystoscope  may  show  that  the  blood  comes  from  one  ureter  only — 
a  suspicious  circumstance  in  doubtful  cases,  for  it  almost  certainly 
excludes  blood  conditions,  and  thus  renders  local  disease  of  some 
description  almost  certain. 


PHOSPHATIC  DIABETES 

Is  too  rare  a  disease,  at  any  rate  in  well-marked  form,  to  require 
any  prolonged  discussion  here,  but  I  mention  it  to  emphasise  the 
one  essential  point  in  its  diagnosis,  viz.  that  the  phosphates  must 
appear  in  the  urine  without  any  treatment  of  the  fluid — heat, 
alkalies,  etc. — and  in  the  absence  of  decomposition.  In  a  typical 
case  they  will  form  a  deposit  equal  to  one-quarter,  or  even  one-half 
the  bulk  of  the  fluid.  The  patient  will  have  few  or  no  complaints 
to  make  except  of  general  flabbiness,  langour,  and  want  of  energy. 
Routine  examination  of  the  urine  will  complete  the  diagnosis  so 
far  as  we  can  at  present  go. 

DIABETES  INSIPIDUS 

Precisely  the  same  remarks  apply  to  this  trouble.  It  is  a  rare 
disease,  of  practically  unknown  causation,  and  needs  only  mention 
to  emphasise  the  caution  not  to  call  mere  temporary  polyuria  by 
the  ominous — to  the  laity — name  of  diabetes.     The  essential  point 


228  DIFFERENTIAL  DIAGNOSIS  chap,  vi 

is  that,  without  rhyme  or  reason — occasionally  a  blow  or  shock 
causes  it — an  otherwise  healthy  person  shall  somewhat  suddenly 
begin  and  continue  to  pass  enormous  quantities,  from  200  ozs. 
upwards,  of  very  light  urine  with  a  very  low  specific  gravity — 1002- 
1005 — and  no  abnormal  constituents.  This,  and  a  corresponding 
thirst,  are  the  only  real  diagnostic  elements. 


CHAPTER   VII 

AFFECTIONS    OF    JOINTS 

The  symptoms  and  physical  signs  of  a  joint  trouble  are,  with  one, 
or  possibly  two  exceptions,  viz.  hysterical  knee  and  the  pain  in  the 
knee  when  the  hip  is  the  seat  of  disease,  sufficiently  obtrusive  to 
leave  no  room  for  diagnostic  difficulty  in  deciding  which  joint  is 
affected ;  but  the  precise  structures  attacked,  and  the  extent  to 
which  they  are  likely  to  be  disorganised  or  destroyed,  with  the  con- 
sequent future  utility  of  the  articulation,  will  commonly,  and  speak- 
ing in  general  terms,  largely  depend  upon  the  third  step  in  diag- 
nosis, viz.  the  exact  etiological  factor  at  work.  Treatment,  too,  will 
very  much  depend  upon  the  same  factor  for  its  nature  and  degree 
of  activity.  Compare  the  almost  passive  expectancy  of  the  local  treat- 
ment of  the  joints  in  simple  rheumatic  fever  with  the  urgent  necessity 
for  evacuating  a  joint  full  of  pus.  Thus,  both  for  prognosis  and 
for  treatment,  exact  diagnosis  is  of  immense  importance. 

The  affections,  the  diagnosis  of  which  I  propose  briefly  to  dis- 
cuss, are : — 

Charcot's  osteoarthropathy  of  tabes     Rheumatic  gout. 

dorsalis. 

Flat  foot.  Rheumatoid  arthritis. 

Gout.  Synovitis  acute. 
Gonorrhoeal  rheumatism.  ,,  chronic. 

Hysterical  joint  troubles.  Tubercle  of  joints. 

Rheumatism.  Traumatism. 

Some  of  them  require  only  to  be  borne  in  mind  for  diagnosis  to 
be  at  once  evident,  while  in  other  cases  a  precise  determination  of 
the  factors  at  work  will  remain  in  doubt  after  all  tests  have  been 


230  DIFFERENTIAL  DIAGNOSIS  chap. 

applied.  We  will  commence  with  an  analysis  of  the  symptoms  and 
physical  signs  as  the  simplest  introduction  to  exact  diagnosis. 

A  patient  who  has,  or  thinks  he  has,  disease  in  or  of  a  joint  will 
come  before  us  complaining  of  one  or  more  of  the  following 
symptoms :  pain  (spontaneous,  or  on  attempted  movement),  stiff- 
ness, grating,  swelling,  heat,  or  redness. 

Pain. — This  is  a  feature  common  to  all  cases,  with  one  excep- 
tion, viz.  Charcot's  joint,  which  is  almost  invariably  (but  not  quite 
without  exceptions)  a  painless  trouble.  The  curiously  misplaced 
reference  of  pain  to  the  knee  (through  the  obturator  nerve),  when 
the  hip  is  the  seat  of  serious  trouble,  must  not  be  overlooked  ;  the 
apparent  shortening — tilt  of  pelvis — and  physical  examination  of  hip 
will  usually  clear  up  difficulties  when  nothing  is  found  in  the  knee. 
For  the  rest  the  character  and  severity  of  the  pain  give  us  a  strong 
guide  to  the  acuteness  or  chronicity  of  the  joint  trouble.  Thus,  in 
acute  gout,  or  a  pyaemic  joint,  the  pain  is  sudden  in  onset  and 
agonising  in  its  character.  In  rheumatism  it  is  usually  not  so  in- 
tense, but  more  v/earying — a  constant  dull  ache.  When  the  bones 
are  affected  the  pain  is  much  worse  at  night,  with  jumping  and 
starting  of  the  limb  on  falling  asleep.  In  more  chronic  affections, 
such  as  chronic  synovitis,  rheumatoid  arthritis  (in  its  chronic  forms), 
pain  is  comparatively  slight  except  on  use,  and  other  features  will 
be  of  more  use  in  diagnosis.  The  exact  situation  of  the  pain  is  a 
matter  of  great  importance,  for  an  abscess  in  a  bone  near  a  joint 
(especially  true  of  the  knee)  has  frequently  been  mistaken  for  joint 
trouble.  If  care  be  taken  to  examine  for  local  tenderness,  especi- 
ally on  tapping  the  bone  a  little  way  off  the  joint.,  the  error  will  be 
likely  to  be  avoided. 

Stiffness. — May  be  of  any  degree,  from  the  absolute  rigidity  of 
bony  anchylosis  to  a  little  difficulty  in  commencing  movement.  In 
its  milder  forms,  associated  with  some  pain  and  aching,  it  may  be 
merely  the  stiffness  of  some  unwonted  exercise.  When  this  is  the 
case  it  will  usually  be  found  that  it  is  really  the  muscles  and  not 
the  joint  (though  the  latter  has  been  accused  by  the  patient)  that  is 
the  seat  of  the  pain.  In  any  case,  there  will  be  the  history  of  the 
exercise  to  guide  us,  and  in  a  few  hours,  or  days  at  the  outside,  it 
will  subside.  On  the  other  hand,  it  may  persist  or  get  worse,  and 
then  we  are  faced  with  two  alternatives:  (i)  it  may  be  that  the 
exercise  (if  there  be  a  history  of  such)  has  excited  a  slight  attack  of 
synovitis :  there  will  then  be  detectable  a  little  effusion  in  the  joint, 
or  local  heat,  or  grating  near  the  joint  (teno-synovitis),  with  con- 
siderable pain;  (2)  especially  if  there  has  been  no  unusual  exercise 


VII  AFFECTIONS  OF  JOINTS  231 

we  must  be  on  our  guard,  and  look  out  for  an  oncoming  attack  of 
sub-acute  or  acute  rheumatic  fever.  The  thermometer  will  in  this 
case  show  a  slight  (may  be  severe)  pyrexia  up  to  100°  or  101°.  If 
there  is  no  rise  of  temperature,  the  nervous  system  must  be  carefully 
examined,  especially  for  sensory  changes  and,  round  the  joint, 
atrophy  of  structures,  etc.  Should  we  still  get  a  negative  reply  to 
our  investigations,  we  have  probably  to  deal  with  a  subject  of  the 
arthritic  diathesis  {vide  p.  244). 

In  its  more  chronic  and  definite  forms  the  stiffness  only  appears 
after  a?t  attack  of  actual  joint  trouble^  and  then  becomes  chiefly  of 
surgical  interest,  to  ascertain  what  precise  structures  are  involved, 
and  how  the  stiffness  can  best  be  relieved.  By  this  time,  i.e.  with 
a  chronic  stiffness,  the  history  will  probably  have  cleared  up  the 
etiology ;  but  if  this  be  unobtainable  or  unreliable,  we  may  bear  in 
mind  that  [a)  bony  anchylosis  is  most  likely  to  have  arisen  from 
severe  traumatism,  recovered  tubercle,  or  pyaemia,  doubtfully  in- 
cluding gonorrhcea  \  {p)  bony  obstruction  without  union,  from 
rheumatoid  arthritis,  or  from  a  Charcot's  joint  with  excessive  pro- 
duction of  bone ;  (c)  thickening  and  stiffening  of  ligaments,  etc.,  from 
gonorrhceal  rheumatism,  or  chronic  rheumatism,  and  possibly  gout ; 
(d)  stiffening  of  skin  and  other  subcutaneous  structures,  from  trau- 
matism (burns,  etc.),  in  all  of  which  characteristic  features  are  nearly 
sure  to  be  present  (vide  below  under  the  appropriate  heading).  To 
determine  whether  bony  union  as  opposed  to  bony  obstruction  is 
present  complete  general  anaesthesia  is  often  essential. 

Grati?ig. — May  be  due  to  loose  bodies  in  the  joint  and  to  acute 
synovitis,  but  in  these  two  affections  it  can  be  produced  by  such 
manipulation  of  the  joint  as  does  not  involve  movement  of  the 
articulation.  In  the  former  case  the  history  of  the  attack  from 
which  relief  is  sought  is  very  characteristic.  Possibly  grating  may 
have  been  pre\-iously  perceived,  but  then  has  followed  sudden  fixa- 
tion with  intense  pain.  In  both  of  them  the  sensation  conveyed  to 
the  hand  is  very  different — less  harsh,  more  like  a  tremor — to  that 
which  is  felt  when  the  cartilage  is  eroded,  and  two  bony  or  rough 
uratic  surfaces  are  rubbed  on  one  another.  This  latter  form  of 
grating  is  only  felt  in  gout,  rheumatoid  arthritis,  or  Charcot's  osteo- 
arthropathy, and  then  the  remaining  factors  are  of  more  importance 
{vide  below). 

Swelling. — The  primary  object  in  examining  a  swelling  in  or 
near  a  joint  is  to  determine  whether  it  is  hard  (bone,  cartilage,  or 
uratic  deposit)  or  whether  it  is  soft,  probably  fluctuating  (synovitis, 
tubercle,   sarcoma,   aneurysm,   etc.).     Very  slight  examination  will 


232  DIFFERENTIAL  DIAGNOSIS  chap. 

soon  determine  this  point.  If  the  swelling  be  hard  (due  to  bone 
cartilage  or  intraosseous  sarcoma)  it  may  be  due  to  (i)  Charcot's 
joint,  in  which  case  the  lumps  will  be  loose  and  movable  on  one 
another,  and  the  joint  will  be  usually  more  movable  than  natural ; 
(2)  osteoarthritis,  when  it  will  be  more  a  lipping  of  the  cartilage, 
an  exaggeration  of  the  natural  outline  of  the  articulatory  ends  of 
the  bone,  and  the  joint  will  have  a  less  extensive  range  of  movement 
than  usual;  (3)  intraosseous  sarcoma — this  will  be  detected  by 
the  swelling  being  a  little  below  or  above  the  joint — of  the  bulk  of 
the  bone  as  opposed  to  its  free  edges — and  possibly  may  give  egg- 
shell crackling.  A  uratic  deposit  will  also  be  hard,  but  its  white 
appearance  (or  even  discharge  from  a  small  opening)  will  scarcely 
allow  of  a  mistake  being  made. 

If  the  swelling  be  soft  (or  fluctuating)  our  first  object  is  to 
determine  whether  it  arises  outside  or  inside  the  joint,  or  both.  If 
purely  outside  a  little  care  will  usually  reveal  the  outlines  of  the 
articulation,  or  a  little  pitting  on  pressure  (the  hip  and  shoulder 
offer  almost  insuperable  difficulties  in  deciding  this  point),  the  arti- 
culation itself  will  usually  work  smoothly  (in  the  hip  and  shoulder 
this  will  be  the  best  test).  If  purely  from  within,  or  from  both,  the 
outlines  of  the  articulation  will  be  obscured  more  or  less  in  some 
positions  of  the  joint ;  this  point  is,  however,  more  difficult  in  theory 
than  in  practice.  In  swelling  outside  the  joint  we  may  have  to  deal 
with  aneurysm  or  sarcoma  of  the  bone  or  bursal  enlargements  ;  the 
former,  unless  cured  or  ruptured,  will  not  only  be  soft,  but  have  an 
expansile  pulsation  of  its  own  ;  sarcoma  will  have  enlarged  the  bone 
some  little  way  from  the  joint,  while  the  contour  of  the  joint  itself 
may  still  be  made  out.  Such  are  the  principal  points  in  typical 
cases,  but  in  some  unusual  ones  the  diagnosis  will  require  many 
examinations,  and  even  then  still  be  left  in  doubt ;  for  Bursal  En- 
largements, vide  below. 

In  a  swelling  which  involves  the  interior  and  exterior  of  a  joint, 
traumatism,  gout,  and  gonorrhoeal  rheumatism  come  in  chiefly  for 
consideration.  Traumatism  will  be  determined  at  once  by  the 
history  ;  for  Gout  and  Gonorrhoeal  Rheumatism,  vide  below.  When 
we  have  determined  that  we  have  to  deal  with  soft  material  entirely 
inside  a  joint,  pus,  clear  synovial  effusion,  and  granulation  tissue 
require  to  be  differentiated.  So  far  as  the  effusion  itself  is  con- 
cerned we  cannot  decide  between  pus  and  clear  fluid,  but  other 
points  will  leave  little  room  for  doubt  between  pyaemia  and  simple 
synovitis.  Between  an  effusion  and  a  growth  of  granulation  tissue 
differentiation  is  usually  tolerably  easy,  either  by  the  pulpy  semi- 


VII  AFFECTIONS  OF  JOINTS  233 

fluctuating  feel  of  the  swelling,  or  (in  the  knee)  by  ascertaining 
whether  the  patella  can  be  "rung"  on  the  femur,  i.e.  whether  we 
can  feel  bone  knocking  on  bone,  or  whether  some  soft  material 
comes  in  the  way,  as  though  the  patella  were  depressed  on  to  a  soft 
cushion  as  it  were. 

Bursal  Enlarge7ne7its. — Are  either  (i)  quite  isolated,  i.e.  not 
communicating  with  the  joint,  or  (2)  provided  with  an  opening  into 
the  synovial  cavity.  In  the  former  case  difficulties  of  priniary 
diagnosis  can  hardly  arise,  for  the  swelling  will  be  readily  movable 
on  the  tissues  which  surround  it  and  the  joint ;  it  will  be  incapable 
of  compression,  though  probably  fluctuating,  while  the  outlines  of 
the  joint  itself  will  be  readily  distinguishable,  and  its  movements 
smooth.  Communication  with  the  joint  cavity  will  be  ascertained 
by  examining  the  swelling  in  many  positions  of  the  articulation, 
when  it  will  be  found  that  in  the  position  of  greatest  capacity — 
usually  one  of  semi-flexion — the  cystic  swelling  becomes  more  lax, 
its  contents  can  be,  partially  at  least,  transferred  to  the  joint  and 
again  expelled  by  a  wide  alteration  in  the  position  of  the  joint. 

Heat — Distinctly  appreciable  by  the  hand  as  a  contrast  to  the 
general  heat  of  the  skin,  will  only  tell  us  that  the  condition  is 
acute ;  in  chronic  joint  troubles  local  heat  is  practically  absent.  Of 
acute  affections,  the  heat  is  remarkable  in  gout  and  sometimes  in 
pyaemia ;  in  traumatism  it  is  fairly  well  marked  as  a  rule,  but  in 
rheumatism  is  either  practically  absent  (milder  or  more  chronic 
cases)  or  is  very  little  noticeable  owing  to  the  great  general  heat  of 
the  skin. 

Redness. — Is  a  pretty  sure  indication  that  the  trouble  is  not 
purely  intra-articular.  Thus,  it  is  scarcely,  if  at  all,  present  in  pure 
rheumatism  (a  synovitis)  in  simple  synovitis,  either  acute  or  chronic; 
in  gonorrhoeal  rheumatism  (a  pan-  and  periarthritis)  it  is  commonly 
fairly  well  marked,  but  in  gout  it  assumes  its  most  intense  and 
remarkable  degree  with  a  peculiar  shiny  condition  of  skin  hardly 
seen  in  any  other  form  of  arthritis  ;  in  fact,  if  a  bright  red,  shiny 
condition  of  the  skin  over  and  round  a  joint  has  appeared  within  a 
few  hours,  with  intense  agony,  in  a  patient  previously  in  fair  health, 
it  is  almost  pathognomonic  of  gout ;  the  only  alternatives  are 
traumatism,  of  which  the  history  will  be  obvious  (and  even  here  we 
must  remember  the  frequency  with  which  slight  traumatism  will 
excite  acute  arthritic  gout),  or  less  commonly  pysemia,  and  here 
there  is  not  likely  to  be  a  freedom  from  previous  symptoms  of 
pyaemia,  a  definite  source  of  the  infection  will  usually  too  be  fairly 
obvious,  e.g.  a  wound,  parturition,  etc. 


234  DIFFERENTIAL  DIAGNOSIS  chap. 

Individually,  then,  it  will  be  seen  that  these  local  physical  signs 
are  rather  frail  reeds  to  rely  upon  for  a  diagnosis,  but  collectively 
{vide  below)  they  form  a  strong  foundation,  and  especially  when 
considered  in  the  light  that  the  history  of  the  case  can  throw 
upon  them.  In  this  history  the  following  points  are  the  most 
important : — 

1.  In  the  Family  History. — Gout,  rheumatic  gout  (probably 
rheumatoid  arthritis),  or  rheumatism  and  its  allies — chorea,  morbus 
cordis,  etc. — in  very  near  relatives  {vide  below,  Arthritic  Diathesis). 

2.  In  the  Previous  Personal  History. — Excess  of  eating  or 
drinking  (especially  beer)  make  gout  seem  more  probable;  chorea  and 
definite  cardiac  disease  make  rheumatism  likely ;  previous  attacks 
of  joint  trouble  similar  or  dissimilar  to  the  present  one  will  also 
have  great  weight. 

3.  In  the  History  of  Onset — 

{a)  Traumatism  to  the  joint  is  obvious  enough,  but 
traumatism  to  a  nerve  (and  other  definite  nerve 
diseases)  must  be  noted  as  a  possible  causative 
factor. 

(/5)  Exposure,  either  general  or  local  (of  a  limb),  is  likely  to 
produce  a  fairly  sudden  onset  of  rheumatism  or  acute 
synovitis. 

{c)  An  attack  commencing  during  sleep  is  ipso  facto  likely 
to  be  gout. 

id)  Whether  more  than  one  joint  was  simultaneously  or  in 
rapid  {i.e.  a  few  days)  succession  attacked.  Gout, 
gonorrhoeal  rheumatism,  acute  synovitis  non-rheuma- 
tic, tubercle  and  Charcot  are  commonly,  at  any  rate 
in  first  attacks,  monarthritic.  Rheumatism  or  rheu- 
matoid arthritis  is  nearly  sure  to  be  at  the  bottom  of 
a  primary  polyarthritis. 

{e)  Which  joint  or  joints  are  affected.  The  proxim.al 
phalanx  of  the  big  toe  is  especially  obnoxious  to  first 
attacks  of  gout,  the  knee  to  gonorrhoeal  rheumatism, 
the  middle  or  proximal  phalanges  of  the  hand  to 
rheumatoid  arthritis,  though  of  course  exceptions  are 
numerous,  and  the  more  so  the  greater  the  number  of 
previous  attacks. 

(/)  In  cases  where  the  patient  is  seen  in  a  second  (or  higher 
multiple)  attack,  an  equally  careful  account  of  the  first 
one  must  be  recorded  if  it  can  be  possibly  attained. 


VII  AFFECTIONS  OF  JOINTS  235 

We  may  now  consider  the  obverse  side  of  the  case,  and  briefly 
enumerate  the  main  diagnostic  points  of  each  individual  trouble, 
commencing  with  the  most  easily  differentiated. 

Charcots  Osteoarthropathy  of  Tabes.  — Rapid  (a  few  months  or  even 
weeks)  onset  of  a  nearly  painless  (so  far  as  the  joint  itself  is  con- 
cerned, but  lightning  pains  in  the  limbs  very  common)  effusion 
into  a  joint,  and  excessive  mobility  of  the  articulation,  should  make 
a  brief  examination  of  the  nervous  system  at  once  obvious  to  the 
mind.  I  am  not  aware  that  the  joint  changes  are  ever  the  first  a?id 
only  signs  of  tabes  ;  loose  bony  outgrowths,  and  (or)  atrophy  and 
total  disorganisation  of  the  original  articulatory  surfaces  are  the 
principal  anatomical  changes.  Some  cases  of  rheumatoid  arthritis 
so  closely  resemble  in  their  local  effects  a  Charcot's  joint,  that  an 
idea  is  existent  that  the  two  diseases  are  alike  in  pathology ;  even 
granting  a  local  identity,  the  remaining  physical  signs  of  tabes  if 
present  must  always,  I  think,  compel  a  diagnosis  of  Charcot,  especi- 
ally if  only  one  (or  two)  joint  be  affected. 

Flat  Foot. — Requires  to  be  mentioned  in  this  connection  because 
the  patients  so  frequently  come  to  us  complaining  of  "  rheumatism  " 
in  the  ankle,  and  often  pain  up  the  calf  of  the  leg.  The  patient 
will  probably  be  a  young  and  over-worked  adolescent,  and  the  pain 
will  only  be  felt  on  or  after  long  standing  on  the  feet.  Examination 
of  the  foot  will  show  that  the  ankle  is  free  from  all  signs  of  disease 
(heat,  swelling,  etc.),  and  that  the  pain  is  really  in  the  scaphoid  or 
head  of  the  astragalus ;  the  arch  will  be  seen  to  be  obviously  fallen 
in — footprints  (from  a  wet  foot)  may  be  taken  to  show  this  more 
accurately.  A  complete  absence  of  pyrexia,  or  general  constitutional 
symptoms,  will  practically,  with  the  above,  settle  the  diagnosis. 

Gonorrhoeal  Rheumatis7n. — Is  apparently  in  its  essence  a  mild 
form  of  pysemic  joint.  In  its  early  stages  will  always,  by  the 
patient,  and  frequently  by  the  medical  man,  be  called  rheumatism  ; 
in  fact,  I  know  of  no  pathognomonic  sign  in  this  stage  to  differentiate 
it,  for  the  local  processes  are  then  identical.  Later,  it  will  be  more 
likely  to  be  thought  of  by  (i)  its  obstinacy  to  remedies;  (2)  its 
confinement  to  one  joint — usually  the  knee — without  others  being 
successively  attacked  during  a  rapid  subsidence  of  the  first  ailing 
joint ;  (3)  the  implication  of  the  outer  structures  of  the  joint,  so  that 
definite  redness,  slight  oedema,  and  an  angry,  suppurative  appearance 
supervenes ;  it  is  a  curious  fact  that  actual  pus  never  does  form 
in  these  cases.  Once  these  phenomena  have  started  suspicion, 
inquiry  must  be  made  as  to  a  present  or  recent — the  arthritis  is 
commoner  in  the  chronic   stage  of   gleet — gonorrhoea   or  vaginal 


236  DIFFERENTIAL  DIAGNOSIS  chap. 

discharge.  In  the  absence  of  more  serious  signs  of  pyaemia,  the 
above  points  will  be  sufficient  to  complete  the  diagnosis.  We  may 
tabulate  the  points  of  difference  between  simple  and  gonorrhoeal 
rheumatism  thus : — 

Simple.  Gonorrhoeal. 

May  or  may  not  have  a  gonorrhoea     Certainly    has    either    an    active 
or  gleet  ;  the  gonococcus  is  not  gonorrhoea  or  more  probably  a 

protective  against  the  rheumatic  subsiding  gleet, 

poison. 

Pyrexia  smarter  and  nearly  sure  to      Pyrexia  may  be  absent,  if  present 
be  present.  will  be  more  irregular  but  per- 

sistent. 

Polyarthritis,   many  joints  recover-     Probably  a  monarthritis,  if  a  poly- 
ing  and  getting  worse  coincidently  arthritis  all  the  affected  joints 

or  consecutively.  became   implicated    before  any 

one  of  them  got  well. 

If  sweating  at  all  it  is  profuse,  and     If   sweating   at    all   it   is   that   of 
will  go  on  all  day  ;    smells  sour.  pyaemia  ;  worse  at  night  or  on 

falling  asleep. 

Simple  synovial  effusion  inside  the      Inflammatory  affection  of  all  tissues 
joint.  in  and  round  the  joint. 

Traumatism. — In  an  acute  attack  the  history  is  of  course  obvi- 
ous ;  but  it  must  not  be  forgotten  that  slight  (or  severe)  traumatism 
may  be  the  starting-point  of  acute  gout,  or  of  any  of  the  more 
chronic  joint  troubles  ;  and  therefore  when  we  are  called  upon  to  read 
the  riddle  of  a  chronic  arthritic  trouble  we  must  not  rest  too  satis- 
fied with  "traumatism,"  but  must  search  the  more  carefully  for  a 
possible  nervous  (chronic  degeneration)  or  constitutional  (heredity, 
dietetic,  toxsemic,  etc.),  element  which  has  thus  prominently  ex- 
hibited itself  in  a  damaged  organ. 

Hysterical  Joint  Complaints. — This  is  a  comparatively  rare  form 
of  neurosis,  at  least  in  a  severe  degree,  found  almost  exclusively  in 
the  female  sex,  and  in  young  adult  life  (say  seventeen  to  thirty-seven), 
and  more  frequent  in  the  knee  than  elsewhere.  Its  principal  char- 
acteristic is  that  the  patient  complains  most  bitterly  of  the  severe 
pain  in  the  joint,  but  on  examination  there  is  not  the  slightest 
sign  of  anything  being  wrong  with  the  structures  (nor  with  the  hip 
when  the  pain  is  in  the  knee) — no  heat,  no  swelling,  no  grating ;  it 
will  then  be  found  as  an  almost  pathognomonic  feature  that  the 
pain  is  just  as  severe  on  slight  touch  as  when  the  joint  is  firmly 
handled,  and  that  when  the  patient's  attention  is  engrossed  in  some 


VII  AFFECTIONS  OF  JOINTS  237 

other  direction  the  pain  on  manipulation  disappears.  Frequently 
complete  anaesthesia  is  required  to  eliminate  some  form  of  anchy- 
losis, so  resolute  is  the  patient  in  preventing  a  movement,  the 
slightest  sign  of  which  she  fmds  exquisitely  painful.  If  under  an 
anaesthetic  there  is  any  effusion  or  grating,  in  fact  anything  patho- 
logical to  touch,  it  is  certainly  not  a  case  of  pure  neurosis. 

Synovitis^  Simple^  Acute,  and  ChiV7iic. — An  acute  synovitis  with 
effusion,  without  any  ostensible  cause  except  local  exposure,  is 
described,  though  personally  I  have  not  seen  a  case.  In  its  local 
manifestation,  it  is  said  to  exactly  resemble  acute  rheumatism,  but 
without  its  general  symptoms.  A  chronic  synovitis  is  by  no  means 
so  rare ;  it  is  usually  started  by  some  slight  injury,  and  is  probably 
maintained  by  continued  use  of  the  joint.  It  is  characterised  by 
being  confined  to  one  joint,  associated  with  no  general  symptoms  ; 
it  consists  of  a  simple  distension  of  the  synovial  cavity  (possibly, 
especially  in  the  knee,  commencing  with  an  external  bursa) ;  there 
is  very  little  pain,  except  on  excessive  use  of  the  joint.  As  it 
occurs  in  practice,  the  only  difficulty  in  diagnosis  arises  when  the 
distension  has  become  so  excessive  as  to  loosen  the  articulatory 
ligaments,  when  it  may  be  mistaken — especially  as  pain  is  so  slight 
— for  a  Charcot's  joint ;  the  absence  of  any  confirmatory  signs  of 
tabes  should  prevent  mistakes. 

Titbercle. — Offers  many  cases  of  doubt  in  the  early  stages,  in 
fact,  there  is  at  first  nothing  pathognomonic  about  it.  That  this 
must  be  so  is  obvious  if  we  bear  in  mind  the  morbid  anatomy  of 
the  trouble.  The  arrival  in  a  joint  of  a  company  of  tubercle 
bacilli  is  not  announced  by  anything  more  than  microscopic 
changes  of  a  very  low  degree  of  inflammatory  character ;  in  this 
stage  it  is  a  matter  of  minute  cell  changes  w^hich  sound  the  alarm 
by  twinges  of  pain.  It  is  only  when  the  granulomata  have,  by 
a  growth  and  aggregation,  reached  a  macroscopical  size  and  bulk, 
that  changes  to  the  examining  (from  without)  eye  or  finger  are  to 
be  found.  It  may  commence  apparently  either  in  the  bone  or 
synovial  membrane.  When  in  the  former,  we  suspect  its  presence 
by  the  pain  and  starting  in  the  joint  being  very  much  worse  at 
night,  and  from  the  fact  that  this  pain  has  arisen — in  one  joint 
only —  spontaneously,  or  from  traumatism  so  slight  that  there  is 
very  great  discrepancy  between  cause  and  effect.  When  in  the 
synovial  membrane,  there  is  as  yet  nothing  to  distinguish  it  from 
simple  synovitis.  As  time  goes  on,  however,  we  get  suspicious, 
because  this  apparently  trivial  joint  mischief  will  not  subside ;  we  look 
around,  and  find  that  the  patient — probably  from  the  first  a  frail- 


238  DIFFERENTIAL  DIAGNOSIS  chap. 

looking  object — is  getting  paler  and  thinner,  inclined  to  mope,  and 
capricious  in  appetite ;  we  hear  of  consumption  in  near  relatives ;  we 
notice  that  the  joint  is  semi-voluntarily  held  in  a  constant  fixed 
position  —  that  of  greatest  ease  —  the  slightest  disturbance  from 
which  causes  pain.  By  this  time  we  have  a  strong  conviction  that 
tubercle  is  at  the  bottom  of  the  mischief,  but  it  is  only  when  pulpy 
masses  can  be  felt  in  the  joint  (in  the  knee  or  elbow),  or  an  abscess 
forms  (in  hip,  ankle,  etc.),  or  the  tissues  external  to  the  joint 
become  chronically  affected  (wrist,  e.^.)  that  this  conviction  gives 
place  to  absolute  ce?iainty. 

Such  is  the  common  history  of  tubercular  arthritis  and  of  its 
diagnosis — let  us  hope  that  appropriate  treatment  will  have  begun 
with  suspicion,  not  have  waited  for  certainty.  It  must  be  remem- 
bered that  now  and  again  cases  of  fulminating  tubercle,  so  to 
speak,  are  met  with  in  which  the  joint  very  rapidly  gets  into  a 
condition  of  acute  panarthritis ;  here  it  is  only  the  absence  of 
any  other  plausible  cause,  and  the  persistency  of  great  thickening 
long  after  the  subsidence  of  acute  inflammatory  symptoms  that  will 
help  us.  For  details  of  individual  joints  text  -  books  of  surgery 
must  be  consulted. 

JV.B. — There  is  one  great  caution  to  give  in  dealing  with 
tubercular  arthritis,  and  that  is  not  to  exclude  tubercle  because 
the  patient  is  old ;  the  disease  is  very  common  in  elderly  people  in 
proportion  to  numbers  alive. 

Rheumatism. — Consists  in  its  morbid  anatomy  of  a  simple  synovitis, 
so  far  as  the  joints  are  concerned ;  and  without  other  factors  are  at 
work,  I  believe,  never  alone  gives  rise  to  any  other  change.  Typical 
acute  or  sub-acute  rheumatic  fever,  with  its  pyrexia  and  sour  sweats 
in  adults  (often,  too,  with  endocarditis),  or  with  its  endo-  or  (and) 
pericarditis,  or  pleurisy,  or  history  of  chorea  in  children,  consisting 
of  a  simple  effusion,  with  pain  running  from  joint  to  joint,  some 
convalescent  or  well,  while  others  are  being  attacked,  cannot  be 
mistaken  for  anything  else.  Its  aberrant  and  chronic  forms  can 
better  be  discussed  with  differential  diagnosis  below. 

Gout. — In  the  joints  is  essentially  associated  with,  if  not  actually 
caused  by,  a  deposit  of  urate  of  sodium  in  the  articular  cartilages. 
It,  with  its  sudden  onset  during  sleep,  the  intensity  of  the  pain,  the 
vivid  red  and  shiny  appearance  of  the  joint,  is  equally  difficult  with 
rheumatic  fever  to  confuse  with  any  other  trouble.  For  doubts 
and  difficulties,  vide  below. 

Rheumatic  Gout.  —  The  very  existence  of  such  a  disease  is 
denied  by  many,  who  dub  it  the  refuge  of  the  diagnostically  desti- 


VII  AFFECTIONS  OF  JOINTS  239 

tute.  For  myself,  I  certainly  feel  inclined  to  admit  its  existence,  at 
least  the  existence  of  more  than  one  factor  producing  the  joints 
called  rheumatic-gouty;  though  I  must  admit  that  many  such 
cases  are  nothing  but  gout,  and  many  are  true  rheumatoid 
arthritis  {vide  below). 

Rheiwiatoid  Arthritis^  Osteoarthritis^  better  Chondroarthritis.  — 
This  is  essentially  at  its  commencement  a  degenerative  proliferation 
of  the  cartilage  cells,  with  an  increase  in  the  bulk  of  the  articular 
cartilages,  "  the  ruling  passion — of  reproduction — strong  in  death," 
but  the  result  is  poor  stuff,  with  early  decay  and  death  stamped  on 
it  at  its  birth.  There  are  two  fairly  marked  types,  (i)  with  (2), 
without  marked  inflammatory  reaction  in  the  other  structures  of 
the  'joint,  especially  of  the  synovial  membrane.  The  former  is 
mainly  found  when  the  disease  attacks  young  people  (it  is  most 
important  to  remember  that  this  affection  is,  aye  frequently,  seen 
in  young  people,  even  in  children) ;  the  latter  is  the  commoner  type 
in  elderly  and  old  patients,  though  here,  too,  it  may  have  been  pre- 
ceded by  attacks  of  the  more  inflammatory  type.  The  principal 
characteristics  of  both  forms — when  the  acute  features  have  passed 
away  in  the  one,  and  under  ordinary  circumstances  in  the  other — 
are  (i)  the  lipping  of  the  cartilages,  so  that  the  outlines  of  the 
joint  are  felt  in  bolder  relief  than  usual;  (2)  grating  in  the  joint; 
(3)  stiffness  and  diminished  mobility ;  (4)  frequently,  and  especially 
in  the  metacarpo-phalangeal  joints,  a  subluxation  of  the  articulation, 
so  that  the  distal  bones  are  diverted  from  their  natural  direction. 


Differential  Diagnosis  of  the  Last  Four  Affections,  viz. 
Rheumatism  (Acute  and  Chronic),  Gout,  Rheumatic 
Gout,  and  Osteoarthritis 

We  may  consider  this  as  it  occurs  in  the  several  epochs  of  the 
affections  : — 

1.  On  the  post-mortem  table. 

2.  After  treatment  has  been  tried  for  a  little  while. 

3.  During  a  first  attack. 

4.  In  a  period  of  quiescence  after  a  first  attack. 

5.  In  subsequent  attacks. 

I.  On  the  post-moptem  table. — This  method  of  diagnosis  comes 
in  very  late  for  purposes  of  clinical  medicine,  and  is  only  occasion- 
ally able  to  give  us  information  which  is  of  use  in  estimating  the 


240  DIFFERENTIAL  DIAGNOSIS  chap. 

morbid  condition  in  the  earlier  affections  of  other  patients.  The 
reasons  why  it  is  of  such  comparative  uselessness  are:  (i)  that  the 
troubles  under  consideration  are  practically  never  fatal  (a  few  cases 
of  rheumatic  fever  must  be  excepted)  in  their  earlier  stages,  when 
commencements  of  morbid  changes  could  be  usefully  studied;  (2) 
that  when  the  advanced  conditions  are  found,  after  death  from 
other  diseases,  the  history  of  the  joint  complaints  has  been 
unrecorded  or  lost  from  the  overwhelming  interest  or  importance  of 
the  later  disease.  However,  the  facts  are  very  simple,  and  diagnosis 
thus  made  is  easy  enough  : — 

If  urate  of  sodium  be  present  in  streaks  or  patches  on  the 
cartilages,  we  know  for  a  certainty  that  gout  has  been  at  work, 
either  alone  or  with  other  factors. 

If  the  cartilaginous  coverings  of  the  bone  inside  the  joint  are 
worn  away,  and  the  bare  bony  surfaces  are  eburnated  or  polished, 
and  there  are  no  traces  of  urates  about,  we  know  for  a  certainty 
that  osteoarthritis  has  been  the  disease. 

If  both  the  above  changes,  viz.  urates  and  eburnation  can  be 
seen,  we  are  justified,  I  think,  in  assuming  that  the  morbid  physio- 
logy of  both,  i.e.  gout  and  rheumatoid  arthritis,  diseases  has  existed, 
and  the  more  shall  we  think  that  osteoarthritis  has  been  present  the 
larger  the  superficial  area  of  the  end  of  the  bone,  this  being  the 
final  representation  of  the  pathological  growth  of  the  cartilage  at 
the  edges  of  the  articulation — the  lipping  to  be  felt  during  life. 

If  the  disease  has  been  a  pure  rheumatism — even  chronic — we 
shall  find  very  little  or  no  organic  change.  In  the  acute  affection 
there  will  be  but  clear  fluid  in  the  joint,  with  very  little  (probably 
none)  congestion  of  the  synovial  fringes.  In  the  more  chronic 
condition  of  rheumatism  there  may  be  a  little  stiffening  of  the 
ligamentous  structures  of  the  joint,  difficult  to  appreciate,  and  it  is, 
I  think,  here  possible  to  meet  with  a  slight  loss  of  cartilage,  sug- 
gestive of  osteoarthritic  changes,  for  I  believe  that  the  frequently 
repeated  onslaughts  of  pure  rheumatism  may  by  their  local  influ- 
ence initiate  (?  carry  to  their  final  stages)  those  changes  which  in 
osteoarthritis  are  started  and  carried  on  by  loss  of  trophic  nerve 
control. 

[If  the  cartilages  are  gone,  the  bone  bare  but  not  eburnated, 
rather  cancellated  (rarefactive  v.  sclerosing  osteitis),  and  loose  bits 
of  bone  are  found,  and  the  joint  flail-like,  we  infer  that  it  is  a 
Charcot's  joint;  though  in  dried  specimens  without  any  history 
we  must  not  forget  the  probable  identity  of  cause  (/.<?.  loss  of  tro- 
phic influence)  between  this  and  osteoarthritis,  and  therefore  the 


VII  AFFECTIONS  OF  JOINTS  241 

possible  identity  of  result  \  though  I  think  a  true  Charcot  never  has 
eburnation.] 

2.  Inferences  fpom  Treatment. — This  method  again  may  be 
looked  down  upon  as  coming  a  little  late  in  the  day ;  but  we  may 
urge  that  as  medicine  is  not,  and  can  never  be  {pace  the  scientific 

•^pharmacologists  and  physiologists)  an  exact  science,  and  as  there- 
fore treatment  often  has  to  be  started  on  empirical  supposition,  it 
is  but  fair  to  allow  us  to  gather  information  as  to  diagnosis  as  we 
proceed ;  and  to  use  the  influence  of  one  form  of  treatment  over  a 
joint  affection  as  a  starting-point  for  endeavours  to  make  a  complete 
deduction  as  to  the  nature  of  such  affection.  Salicylate  of  sodium 
is  the  drug  above  all  others  which  is  now  likely  to  be  tried  in  all 
doubtful  cases  of  joint  trouble,  and  so  great  is  the  influence  of  this 
drug  (amounting  almost  to  a  genuine  specific)  over  pure  rheumatism, 
that  it  has  become  a  nearly  fixed  article  of  medical  faith  that  "  the 
greater  the  relief  afforded  to  pain,  pyrexia,  and  general  discomfort, 
the  greater  the  share  of  rheumatism  in  the  production  of  the 
trouble."  If  the  relief  be  speedy  and  complete,  the  diagnosis  of 
pure  rheumatism  is  assured ;  if  relief  be  not  at  least  very  marked, 
we  at  once  suspect,  no  matter  what  the  age  of  the  patient  (I  have 
already  noted  the  frequency  of  acute  symptoms  of  rheumatoid 
arthritis  in  young  subjects),  that  there  are  factors  in  the  trouble 
which  are  likely  to  lead  to  permanent  changes  in  the  joint,  and 
consequent  crippling ;  we  must  carefully  search  for  a  gonorrhoea  or 
gleet,  and  inquire  more  anxiously  into  family  history.  There  is  one 
important  exception  to  be  made  to  this  usual  rule  of  the  influence 
of  salicylates  over  rheumatism,  viz.  that  if  rheumatism  attacks  an 
individual  who  has  had  a  long  or  severe  drain  on  his  constitutional 
strength,  we  find  salicylates  much  diminished  in  utility  or  even  quite 
useless ;  I  have  met  with  such  cases  in  women  after  prolonged 
lactation,  in  adolescents  who  have  been  poorly  fed  for  years,  and  I 
suspect  that  in  the  rheumatism  so  common  after  scarlet  fever  the 
same  conditions  may  hold. 

3.  During"  a  First  Attack. — This  is  naturally  the  time  when 
diagnosis  is  most  required ;  more  perhaps  for  the  sake  of  our  own 
reputations  as  prophets,  and  for  the  advice  we  are  to  give  as  to 
warding  off  future  or  progressive  trouble,  than  for  the  immediate 
sake  of  the  patient,  for  whom  any  sensible  treatment  is  little  likely 
to  be  at  once  disastrous.  The  previous  paragraphs  on  symptoms 
and  pathology  have  already  indicated  the  directions  in  which  diag- 
nostic aid  is  to  be  sought,  but  for  the  sake  of  emphasis  we  may  here 
tabulate  some  of  the  cases,  and  offer  a  few  general  remarks. 

R 


242 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


In  young  subjects — say  under  twenty-five — gout  is  so  rare  that 
unless  it  be  a  very  typical  case — nocturnal  onset,  one  joint,  intensely 
painful,  very  shiny  and  red — or  unless  there  be  a  very  strong  and 
direct  family  history  of  gout,  this  disease  may  be  excluded,  and  the 
problem — except  for  tubercle  {vide  p.  237) — becomes  simple  rheu- 
matism V.  rheumatoid  arthritis. 

They  are  alike  in — 

1.  Many  (and  any)  joints  are   simultaneously  or  in  the  same 

attack  affected. 

2.  There  is  often  effusion ;  it  is  in  the  rheumatoid  arthritis  of 

young  subjects  that  effusion  is  commoner,  and  that  with 
pyrexia  and  general  symptoms. 

3.  The  trouble  appears  to  be  a  synovitis. 

4.  There  is  no  grating  in  a  first  attack. 


They  differ  in — 

True  Rheumatism. 

Cardiac  bruits  and  serous  inflam- 
mation very  common ;  more  com- 
mon the  younger  the  patient. 

A  sequence  of  joints  very  com- 
monly affected,  so  that  different 
stages  are  found  in  the  same 
case. 

Shape  of  joint  pretty  natural,  ex- 
cept for  effusion  into  its  cavity. 


Sweating  very  common,  and  of  a 
peculiar  sour  smell ;  this  is  less 
marked  the  younger  the  patient. 

Fibrous  nodules  occasionally  seen 
in  fibrous  tissue  about  a  joint. 


Rheumatoid  Arthritis. 

Cardiac  bruits  have  no  known  con- 
nection with  the  affection,  and 
if  present  have  had  a  previous 
origin. 

Sequence  of  joints  not  well  marked; 
usually  many  at  the  same  time, 
especially  if  the  small  joints  are 
attacked  ;  very  often  only  one  or 
two  larger  joints  affected. 

Shape  of  joint  a  peculiar  spindle, 
as  though  atrophy  above  and 
below,  and  the  joint  enlarged  in 
the  middle ;  especially  notice- 
able in  phalangeal  articulations. 
This  probably  means  that  there 
is  a  slow  outgrowth  of  cartilage 
before  the  symptoms,  possibly 
also  a  slight  atrophy  of  struc- 
tures above  and  below  the  joint. 

Sweating  not  a  marked  feature, 
and  if  present  has  no  sour  smell. 

Fibrous  nodules  not  seen. 


VII  AFFECTIONS  OF  JOINTS  243 

True  Rheumatism.  Rheumatoid  Arthritis. 

Pyrexia  and  heat   of  skin   usually      Slight     pyrexia     may    be     present 
marked.  though    not    common ;    skin    in 

general    is    certainly  not  hot  to 
the  touch. 

In  middle  age,  or  rather  from  twenty-five  up  to  say  forty-five, 
true  gout  becomes  more  frequent  as  the  cause  of  a  first  attack,  and 
according  to  my  experience  rheumatoid  arthritis  is  less  frequent,  at 
least  until  thirty-five  be  past,  when  it  again  has  an  increase.  It 
is  between  twenty-five  and  forty-five  that  I  believe  chronic  rheuma- 
tism— a  form  without  much  pyrexia  or  swelling,  only  a  little  pain 
and  stiffness — is  a  very  prevalent  affection ;  though  I  admit  it  is 
very  difficult  to  draw  a  hard  and  fast  line  between  this  affection 
and  rheumatoid  arthritis  {vide  Diathesis  below).  In  old  age,  say 
from  fifty-five  upwards,  I  believe  that  first  attacks  of  gout  again 
become  rarer,  and  that,  too,  in  proportion  to  age,  while  (tubercle 
and)  atrophic  changes  of  an  osteoarthritic  or  crippling  character 
become  the  prevailing  affection. 

4.  In  a  Period  of  Quiescence  after  a  First  Attack. — It  is  in 
this  period  that  we  have  to  look  out  for  stiffness,  grating,  or  de- 
formity as  evidence  of  the  local  trouble,  and  general  symptoms 
that  can  be  attributed  to  the  constitutional  affection  of  which  the 
arthritic  attack  may  have  been  only  an  outward  manifestation. 

True  rheumatism  wiU  have  left  practically  no  objective  evidence 
of  its  presence ;  a  little  stiffness  and  slight  pain  that  gets  less  and 
less  are  its  only  sequelae.  It  may  be,  however,  that  slight  pyrexia! 
outbreaks,  with  a  little  local  joint  trouble,  remind  the  patient  that 
his  disease  is  scotched  only,  and  not  killed;  and  these  are  the 
cases  which,  in  my  opinion,  have  a  tendency  to  eventuate  in  crip- 
pling osteoarthritis  as  age  creeps  on.  These,  too,  are  the  cases 
which  in  young  people  are  so  affected  by  changes  in  the  weather. 
I  believe  that  when  a  young  person  admits  himself  a  living  baro- 
meter he  is  the  subject  of  true  chronic  rheumatism,  which  in  his 
later  years  is  likely  to  become  crippling.  Pleurisy,  pericarditis, 
endocarditis,  occurring  on  very  slight  or  no  provocation,  will  also 
throw  light  on  the  rheumatic  nature  of  a  previously  doubtful  joint 
attack. 

If  the  attack  has  been  acute  rheumatoid  arthritis,  the  stiffness 
is  never  likely  to  so  completely  disappear ;  a  grating  and  deformity, 
vA\\\  possible  subluxation  of  joint,  will  probably  soon  make  their 
appearance.     On  true  rheumatoid  arthritis  my  experience  is  that 


244  DIFFERENTIAL  DIAGNOSIS  chap. 

in  young  subjects  weather  has  no  influence ;  it  is  only  when  age 
creeps  on  that  such  appears  to  be  the  case,  but  then  I  beUeve  it 
is  more  due  to  the  effect  on  senile  tissues  in  general  than  on  the 
joints  in  particular,  and  hence  an  elderly  living  barometer  does  not 
thereby  tell  us  much  to  aid  differential  diagnosis.  Beyond  the 
obstinacy  to  treatment,  and  the  local  changes,  there  are  no  con- 
stitutional sequelse  and  complications. 

If  the  attack  has  been  modified  (typical  will  have  been  easily 
recognised)  gout,  then,  as  in  epileptics,  the  patient  will  probably 
express  himself  as  feeling  very  much  better  in  general  health  than 
before  the  attack.  Tophi  must  be  carefully  searched  for,  and  the 
urine  should  be  examined  pretty  frequently  for  any  excess  of  uric 
acid  or  diminution  in  total  nitrogenous  output,  hinted  at  by  a  low 
specific  gravity. 

5.  In  Subsequent  Attacks. — But  little  remains  to  be  said  under 
this  head.  If  the  history  of  the  first  attack  {q.v.)  be  not  available, 
the  evidence  from  all  sides — family,  constitutional,  and  local — will 
have  been  steadily  accumulating,  and,  though  some  features  may 
still  remain  obscure,  the  main  points — the  tophi  and  urine  of  gout, 
the  cartilaginous  outgrowth  of  osteoarthritis,  the  morbus  cordis 
with  but  slight  local  arthritic  damage  of  rheumatism — will  be  almost 
sure  to  point  only  too  clearly  to  the  correct  diagnosis. 


THE  ARTHRITIC  DIATHESIS 

Personally,  I  am  indebted  to  the  writings  of  Mr.  J.  Hutchinson 
for  this  expression ;  that  he  was  the  first  to  utter  it,  is  not  likely, 
for  the  idea  conveyed  by  it  must  have  been  present,  one  might  say, 
for  centuries,  in  the  mind  of  the  profession.  Whatever  its  origin,  I 
accept  it  as  clearing  up  and  harmonising  many  of  the  doubts  and 
difficulties  in  arthritic  diagnosis. 

I  will  first  define  precisely  what  I  mean  by  the  expression.  It  is 
this:  that  there  are  certain  people  who,  owing  to  the  intrinsic 
quality  either  of  the  joint  structures  (bones,  ligaments,  cartilages, 
and  synovial  membranes)  themselves,  or  of  the  nerves  which  un- 
doubtedly govern  their  nutrition,  find  themselves  in  this  position, 
— when  from  exposure,  diet,  or  other  unfavourable  environment, 
a  blood  dyscrasia  or  other  constitutionally  morbid  state  arises  of 
such  a  nature  that  some  tissues  are  likely  to  suffer  from  imperfect 
nutrition  ;  the  joint  tissues  above  mentioned,  or  their  nerves,  are  the 
parts  of  the  organism  upon  which  the  stress  will  first  fall :  they  are 


VII  AFFECTIONS  OF  JOINTS  245 

the  structures  to  suffer.  Furthermore,  when  once  such  a  morbid 
local  process  has  been  thus  started  in  the  joints,  there  is  in  these 
people  (i)  a  greater  tendency  than  in  others  for  the  process  to 
extend  ;  (2)  a  probability  that  it  will  in  this  extension  lose  any 
possible  specific  character  it  may  have  originally  possessed — gouty, 
rheumatic,  etc.  —  and  become  generally  and  indiscriminately  de- 
generative and  destructive;  (3)  a  greatly  diminished  and  less  ready 
capability  of  repair  if,  and  when,  the  constitutional  dyscrasia  has 
disappeared.  Finally,  to  complete  the  story,  I  believe  that  though 
in  the  main  such  joint  vulnerability  is  an  inborn  or  hereditary — it 
may  be  from  fairly  remote  ancestry — property  of  the  individual,  it 
may  be  acquired  by  personal  habits  and  total  environment  {vide 
p.  7),  and  then  in  some  degree  (?  crescendo)  transmitted,  but  this 
transmission  need  not  be  an  accurate  and  identical  one,  just  as  an 
epileptic  need  not  necessarily  have  an  epileptic  child,  but  one  that 
is  generally  weak  in  the  nervous  system ;  so  I  believe  a  gouty  or 
rheu77iatic  ancestor  may  have  generally  arthritic  descendants. 

These  generalised  laws  or  propositions  which  have  been  framed 
not  by  deduction — from  few — but  by  induction — from  many  cases 
— constitute  the  explanation  of  the  expression  "  crippling  changes  " 
which  I  have  several  times  used,  intending  thereby  to  represent 
the  generalised  destructive  processes  which  proceed  from  originally 
specialised  causes.  They  explain  the  identity  of  the  pathological 
anatomy  of  a  Charcot's  joint  with  that  of  an  advanced  osteoarthritic 
one,  and  of  the  latter  with  that  of  a  chronic  rheumatic  joint  in  which 
the  diseased  process  has  overstepped  its  natural  boundary  of  the  syn- 
ovial membrane,  and  led  to  destruction  of  ligaments,  etc.  j  and  this 
ultimate  anatomical  identity  proves  how  impossible  it  is  in  chronic 
joint  troubles  to  be  certain  that  simple  syno\dal  rheumatism  will 
not,  clinically^  in  the  long  run  assume  the  features  of  rheumatoid 
arthritis. 

They  possibly  give  us  a  clue  to  the  reason  why  gonorrhoeal 
rheumatism  is  so  rare  compared  with  a  urethral  discharge,  and  why 
tubercular  joints  are  much  less  frequent  than  phthisis. 

Their  bearing  on  the  family  history  of  a  case  of  joint  affection 
is  important,  but  not  decisive;  they  explain  at  once  the  "why," 
but  they  do  not  directly  give  us  the  "how,"  of  a  particular  attack. 
There  can  be  no  doubt  about  the  influence  on  diagnosis  of  a  definite 
history  of  rheumatic  fever,  or  of  gout,  in  immediate  ancestors  or 
very  close  collaterals  ;  but  when  we  hear  that  a  father,  mother, 
uncle,  aunt,  or  grandparent  had  suffered  at  an  advanced  age  from 
rheumatic  gout,  the  specific  indication  is  very  much  weakened,  and 


246  DIFFERENTIAL  DIAGNOSIS  chap.vii 

we  are  thrown  more  completely  on  to  local  signs  for  the  precise 
diagnosis ;  a  creaking,  stiffened  joint,  a  small  tophus  in  the  ear  or 
elsewhere,  a  cardiac  bruit,  etc.  In  conclusion,  let  me  emphasise  a 
final  statement — because  or  when  we  can  find  a  hint  of  this  pre- 
disposition we  must  not  rest  content  with  it,  we  must  be  all  the 
more  anxious  to  find  the  precise  local  factor  in  its  earfiest  stages ; 
for  it  is  only  in  these  that  treatment  is  even  likely  to  be  curative. 
When  destruction  is  widespread  and  irreparable,  precise  diagnosis 
may  be  interesting  scientifically,  but  it  is  of  precious  little  use  to 
our  patients,  who  must  ever  be  the  first  care  in  our  minds. 


CHAPTER   VIII 

DISEASES    OF    THE    NERVOUS    SYSTEM 

Section  I. — Anatomy  and  Physiology  of  the  Nervous  System 

Before  the  problems  of  regional  and  pathological  diagnosis  of 
nervous  affections  can  be  intelligently  discussed  or  tabulated,  it  is 
absolutely  essential  to  sketch  in  slight  detail  the  anatomy  and  con- 
nections of  nerve  structures,  and  the  functions  they  are  assumed  or 
proved  to  possess. 

Recent  researches  into  the  microscopic  anatomy  of  the  nervous 
system  have  rendered  it  very  probable,  if  not  actually  proved,  that 
all  nerve  structures,  without  exception,  from  end  bulbs  or  taste  cor- 
puscles to  cerebral  hemispheres,  are  built  up  of  neurons,  and  that 
these  neurons  or  nerve  units  are  all  formed  on  the  same  structural 
plan,  varying  only  in  details  of  size  of  cells,  length  and  number  of 
processes,  etc.,  and  of  course  in  physiological  function.  Each 
neuron,  then,  consists  of: — 

(i)  A  Cell  with  Large  Nucleus. — The  substance  of  the  cell 
shows  a  very  fine  fibrillar  constitution  with  minute  granules  between 
the  fibrillae.     The  body  of  this  cell  gives  off — 

(2)  Numerous  Processes^  all  of  which  ultimately  end  in  dendrites, 
and  one  at  least  of  them  becomes  the  axis  cylinder  of  a  nerve  of 
ordinary  anatomy ;  this  latter  is  spoken  of  as  the  neuraxon. 

(3)  Dendrites. — An  expression  used  to  designate  the  extremely 
fine  fibrillulse  which  form  the  final  endings  of  all  the  processes  of 
the  neuron  cell.  It  is  by  the  interlacing  of  these  dendrites — aptly 
termed  by  Foster  a  synapsis — that  separate  neurons  are  brought 
into  physiological  or  functional  connection  with  one  another,  though 
it  must  be  clearly  understood  that  no  structural  or  anatomical  con- 
tinuity has  been  proved  to  exist  between  the  dendrites  of  different 
neurons ;  in  fact,  the  assumption  is  that  dendrite  acts  on  dendrite 


248  DIFFERENTIAL  DIAGNOSIS  chap. 

in  a  manner  analogous  to  that  of  the  action   of  the  primary  and 
secondary  coils  in  an  induction  electric  machine. 

The  terminals  of  sensory  organs  and  the  end  plates  of  motor 
nerves  in  muscles  are  probably  nothing  more  than  neurons  of  very 
abbreviated  dimensions.  With  these  exceptions,  and  possibly  some 
in  the  cord  and  brain,  all  neurons  possess  processes  of  measureable 
length,  and  the  neuraxons  may  be  (as  in  the  nerves  of  the  extremities) 
many  inches  long  ;  but,  except  for  this  variation  in  length  of  the  cell 
processes,  th^y  are  all  identical  in  structure,  and  collectively  build 
up  the  whole  nervous  system.  Accepting  this  as  the  anatomical  unit, 
we  may  now  proceed  to  consider  how  these  units  are  combined. 

TABULAR  VIEW  OF  THE  ANATOMY  OF  THE 
NERVOUS  SYSTEM 

A.  End  Organs  or  Terminals^  each  probably  a  very  abbreviated 

neuron  : — 

^     ,      ^.  fVoluntary    muscles    under    control 

Contraction  ^     .,/ 

,  \      oi  will. 

T^  1        .  1  Involuntary  muscle  fibres  of  heart, 

Relaxation.  i  ,      i  ,       •  . 

\^      Dlood-vessels,  viscera,  etc. 


I.   In  muscles  in- 
tervening in 


\  Sensation  of  nature  and  amount  of  contraction  and 
relaxation  of  voluntary  muscles  =  muscle  sense.  If 
such  sensory  structures  exist  in  involuntary  muscle 
they  produce  in  health  no  percept  on  the  general 
sensorium. 

(Touch. 
Variations  in  temperature. 
P  ■ 
All  other  cutical  stimuli. 
fSight. 


In    special    sense    organs     sub- 
serving       .... 


Hearing. 

Taste. 

Smell. 


4.  In      glands      and     membranes /Absorption. 

governing    ....    \  Excretion. 

5.  In  all  other  tissues  of  the  body    ^     '    ,  , 

.  ^      ,.  J  .    .      -^  Growth,  and 

superintending  and  regulating  j  „  ' 

B.   The  Peripheral  Nerves. — These  are   the   main  trunks  (neu- 
raxons   and    collaterals)    of  the  neurons  •    they  possess  dendritic 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


249 


endings,  and  synapses  with  the  end  organs  ;  they  conduct  slimuU  or 
impressions  to  and  from  the  end  organs,  thus  constituting  telegraph 
wires  between  the  brain  and  cord  and  every  part  of  the  body.  The 
exact  anatomical  relationship  and  distribution  of  the  peripheral 
nerves  constitute  a  branch  of  ordinary  descriptive  anatomy,  an 
accurate  and  reliable  knowledge  of  which  is  essential  for  the  finer 
minutiae  of  the  differential  diagnosis  of  peripheral  (and  other)  lesions. 
A  detailed  description  would  in  this  book  be  out  of  place. 

C.  The  Spi?ial  Cord. — This  constitutes  a  collection  and  primary 
arrangement  of  the  connections  between  the  brain  and  the  periphery. 
A  transverse  section  (cr  longitudinal  one)  accordingly  presents  a 
picture  composed,  so  far  as  nervous  elements  are  concerned,  of 
certain  groups  of  cells  and  bundles  of  fibres  all  cut  in  various  sections 
according  to  their  direction.  Those  groups  and  bundles,  which  are 
tolerably  well  known  and  understood,  may  be  thus  tabulated : — 

Cells  of  the  Cord 


In  anterior  cornua  (the  main 
bulk  of  them,  at  any  rate). 

In  Clark's  column. 


Others  scattered  through  the 
gray  matter,  and  possibly 
some  of  anterior  cornua. 


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Anterior  roots  or  peripheral 
motornerves, possibly  also 
of  vasomotor  nerves. 

Nerves  to  and  from  viscera, 
and  to  and  from  direct 
cerebellar  tract. 

Neurons  or  nerve-tracts,  with 
origin  and  dendritic  termi- 
nals totally  within  the  cord. 


Fibres  of  Cord 


Posterior  median  column.  "^ 
Posterior  external  „  > 
Posterior  roots.  J 

Lateral  pyramidal  tracts.    ) 
Direct  „  „       j 

Ascending  antero-lateral  tract 
of  Cowers. 


Anterior  roots. 
Direct  cerebellar  tract. 


Many  unnamed  fibres,  both  in 
white  and  gray  matter. 


a 
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The  ganglion  on  the  posterior 
root  of  peripheral  nerves. 

Rolandic     or    motor    area    of 

cerebral  cortex. 
The     reticular     formation     of 

medulla  and  pons,  and  also 

in  the  ordinar}^  gray  matter 

of    cord,      as      intracordal 

neurons. 
xA.nterior  cornua. 
Clark's  column,  and  probably 

also  cerebral  and  cerebellar 

cortex. 
In    gray    matter  =  intracordal 

neurons. 


250 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


D.  The  Medulla  Oblojigata. — Structurally,  this  is  the  continua- 
tion upwards  of  the  cord,  but  the  arrangement  of  its  neuron  cells 
and  stems  is  more  complicated  and  intricate.  Only  the  more 
important  (as  far  as  our  present  knowledge  is  concerned)  and 
apparently  simple  ones  are  here  tabulated : — 

Cells  of  the  Medulla 


Groups  just  below  the  floor  of 
the  fourth  ventricle  in  serial 
continuation  of  those  of  the 
anterior  cornua. 


fFuniculus  gracilis. 
Groups  in-!         „         cuneatus. 
[        ,,         rolandi. 


Groups   scattered  through  the 
reticular  formation. 


s  ° 

^  S 

^  I 

O  X 

W3  Vh     o 

(D  3     o 

y  <U    <U 

P  fl    '-' 

C  ^ 

O 


CTj 


Twelfth  nerve,  or  hypoglossal. 

Eleventh  nerve,  or  spinal 
accessory. 

Tenth  nerve,  or  pneumogastric 

Ninth  nerve,  or  glosso- 
pharyngeal. 

Eighth  nerve,  or  auditory. 

Tracts  to  cortex  of  cerebellum 
and  cerebrum,  to  the  former 
by  therestiform  body,  to  the 
latter  through  the  reticular 
formation  and  fillet. 

Antero  -  lateral  ascending 
tract.     Posterior  columns. 


Fibres  of  the  Medulla 


Pyramidal  tracts. 

Funiculus  graciHs. 
,,         cuneatus. 
,,        rolandi. 


Direct  cerebellar  tract. 


Cranial    nerves    from  sixth   to 
twelfth. 


6 


A 

■i-> 
O 

a 
o 


bo 


Motor  cortex  of  brain. 

Posterior  root  ganglion,  and 
also  (above  the  cells  of  the 
funiculi)  cells  of  cortex  of 
cerebrum,  and  cerebellum. 

Clark's  column,  and  also  cere- 
bellar cortex. 


Cells    in 
tricle. 


floor    of   fourth    ven- 


E.  T/ie  Pons. — The  main  bulk  of  the  superficially  visible  fibres 
run  in  a  transverse  direction ;  the  deeper  parts  are  really  the  con- 
tinuation upwards  of  the  medulla.  The  cells  and  fibres  most  essen- 
tially pontine  are  the  following  : — 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


251 


Cells  of  Pons 


Groups    round  the  central 
canal. 

Groups  in  the  roof. 


>  0^     (/) 

SJ  <«  £  -S 

W      <U  o      >^ 

U  <+5      U 


Fourth  nerve. 

Third     ,,    (chief oculo-motor). 

Going  to  cerebrum  and  cere- 
bellum. 


Fibres  of  Pons 


Transverse. 

Oblique. 

Vertical  or  pyramidal. 

Transverse  and  oblique, 
passing  in  all  direc- 
tions. 


g   bo 

"^   o 
u 


OJ    o 


o   u 


Cerebellum. 

Cerebrum  and  cerebellum. 

Motor  cortex  of  brain. 

Probably  scattered  through 
the  whole  cortex  of  cere- 
brum and  cerebellum  and 
formatio  reticularis,  and 
also  basal  ganglia. 


F.  Cerebrum  and  Cerebellum. — In  these  organs  the  connections 
and  arrangements  of  neurons  attain  their  highest  degree  of  com- 
plexity and  obscurity.  Some  few  we  think  we  know,  but  of  the 
vast  majority  our  knowledge  is  practically  nil.  In  the  section  on 
cerebral  localisation  more  details  of  the  anatomy  and  functions  of 
the  brain  will  have  to  be  given.  For  our  present  purposes  the  fol- 
lowing table  will  be  sufficient : — 

Cells  of  Cerebrum  and  Cerebellum 


Ascending  frontal  parietal 
and  rest  of  motor  cortex 
so  called. 

Frontal  lobes. 


y  '^ 

Oh 

o 

U     oj     tfl 


Corona  radiata,  anterior  two- 
thirds  of  posterior  limb  of 
internal  capsule  and  pyra- 
midal tracts. 

Fibres  running  antero  -  pos- 
teriorly to  opposite  cerebellar 
lobes,  and  to  the  rest  of  cortex 
cerebri  also. 


252  DIFFERENTIAL  DIAGNOSIS  chap. 

Fibres  of  Cerebrum  and  Cerebellum 

Of  frontal,  occipital,   and  tempore  -  sphe-  Convolutions    of    same 

noidal  convolutions.                                      w  side  and  of  opposite 

o  «^  side  (through  corpus 

2  vn  callosum). 

.^  '?^  Convolutions    of    cere- 


u 

r*       bellum. 


to 


of  motor  convolutions.  -g  bo  Oray  matter  of  cortex. 

of  internal  capsule.  g 


c 


...                                   ^  r^  TO    /^  Frontal  cortex. 

of  anterior  limb.                                   I  -5  t;J    I  t,^   , 

...     I  rt  *"     I  Motor  cortex. 

of  posterior    „   anterior  two-thirds.  V  ^        \  r\     ■   •.  ^      j^ 

.^                 "              .               1  •    1  "^         J  Occipital andtemporo- 
of         „          „   posterior  one-third.                  I          i,       -j  i        i. 

"  "  -^  J  \      sphenoidal  cortex. 

Note. — Between  the  anterior  and  posterior  roots  of  the  spinal 
cord  on  the  one  hand,  and  the  cerebral  hemispheres  on  the  other, 
there  is  a  total  decussation  of  impulses,  if  not  of  actual  fibres.  But 
such  functions  and  anatomical  connections  as  the  cerebellum  exerts 
on,  and  possesses  with,  the  cord  are  apparently  not  crossed. 

After  this  brief  dogmatic  sketch  of  the  structural  connections  of 
the  nervous  system,  we  must  proceed  to  a  similar  tabulation  of  the — 


FUNCTIONS  OF  NERVE  MATTER 

We  will  commence  as  before  with  The  Neuron. 

1.  The  Cell. — While  there  is  still  some  dispute  as  to  whether 
the  cell  possesses  any  function  of  a  transforming  or  reinforcing 
character,  there  is  unanimity  in  accepting  a  purely  nutritive  function 
as  the  chief,  if  not  the  only,  function  properly  belonging  to  the  cell. 
At  any  rate,  it  is  a  clinical  fact  that  neuraxons,  collaterals,  and  den- 
drites, and  consequently  the  synapses  of  the  dendrites,  all  undergo 
complete  degeneration  and  death  when  separated  from  the  neuron 
cell,  or  when  the  neuron  cell  itself  is  killed ;  and  nutritive  disturb- 
ance of  the  cell  is  rapidly  followed  by  similar  changes  in  the  other 
parts  of  a  neuron,  and  structures  (non-nervous,  e.g.  muscles)  to 
which  the  nerves  are  distributed. 

2.  Neuraxons  and  Collaterals. — The  only  ascertained  function 
of  these  parts  of  a  neuron  is  to  transmit  unchanged  along  their  length 
impulses  derived,  or  started  {a)  from  sources  external  to  the  body, 
including  in  this  term  food  in  the  alimentary  canal,  and  air  and  its 
impurities  in  the  air  passages,  as  well  as  stimuli  applied  to  the  skin, 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


253 


etc.,  (fi)  from  the  synapses  with  dendrites  of  other  neurons.  They 
are  thus  purely  and  absolutely  analogous  to  telegraph  wires,  carrying 
to  and  from  every  structure  of  the  body  messages  which  result  in 
the  performance  of  every  possible  physiological  process,  whether 
motion,  perception,  nutrition,  secretion,  etc. 

3.  Deiidrites^  a?id  Sy?iapses  of  Dendrites. — It  is  by  these  we  now 
assume  that  impulses  are  transmitted  from  neuron  to  neuron,  and 
transformed  in  character.  It  would  seem  as  though  the  synapses 
afforded  an  opportunity  for  a  sort  of  inductive  action  of  neuron  on 
neuron ;  the  actual  resultant  of  any  impulse  from  any  source 
depending  upon  the  inherent  qualities  of  the  neuron  brought  into 
induced  action  and  its  connections  {a)  with  other  neurons  to  which 
the  impulse  may  be  again  transmitted,  or  (b)  with  terminal  organs, 
muscle,  gland  cell,  or  other  tissue  capable  of  exhibiting  a  final 
resultant. 

Peripheral  Nerves. — As  these  are  simply  neuron  complexes, 
their  functions  in  gross  are  those  of  their  units;  in  detail  they 
carry  the  impulses  which  eventuate  in — 

A. — Movements  in  Voluntary  Muscles  which — 


In  Health. 

Are  possible  to  an  amount  known 
by  experience  to  each  indi- 
vidual ;  are  under  the  control 
of  the  will,  and  capable  of  co- 
ordination for  any  purpose. 


In  Disease. 

Are  weakened,  or  absent,  or  inco- 
ordinated. 

J  Time  or  order. 
\Amount. 
Involuntary  J  Tonic, 
spasms.      \  Clonic. 


In   volition 


B. — Sensory  Perceptions — 


A  known  experience  of  the  indi- 
vidual, differing  materially  in 
different  individuals. 


Excessive  ^ 

Weakened 

Lost 

Delayed 

Perverted 


in       [Temperature, 
-relation-!  Pain, 

to       [Touch,  etc. 


C. — Reflex  Processes^  any  of  which  may  incidentally  affect 
consciousness  and  become  a  percept.  They  are  divisible  into 
three  groups : — 

Group  I. — Experimental,  or  acting  through  cutaneous  external 
stimuli :— 


254 

Superficial — 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


In  Health.  In  Disease. 

Plantar,    cremas-     Present,  but  somewhat     Obviously  increased. 
teric,  etc.  variable  in  amount.  ,, 

Absent. 


decreased. 


Deep — 

Knee  jerk. 
Elbow  jerk,  etc. 


Present,  but  also  some-     Increased,  diminished, 
what  variable.  absent. 


Group  II. — Natural  from  the  viscera  with  contents  or  condi- 
tion for  stimulus,  and  involuntary  movement  or  secretion,  etc.,  as 
the  resultant.  Of  these  there  must  be  very  many,  but  in  only  a 
few  cases  and  conditions  are  of  much  use  to  us  clinically : — 


Those  of  bladder. 
,,        rectum. 


In  Health. 

Co-ordinated  for  pur- 
poses of  voluntary 
micturition  and  de- 
faecation. 


In  Disease. 
Inco-ordinated,        and 
often  removed  from 
voluntary  control. 


Group  III. — Vasomotor  regulating  the  supply  of  blood  to  a 
part — 

In  Health.  In  Disease. 

The  essential  point  is  the  local  control  over     This  local  control  Is  fre- 
local  blood  supply.  quently    lost     or     per- 

verted. 

D.  Trophic  Influences. — Clinical  evidence,  as  well  as  experi- 
mental, tends  to  suggest  that,  besides  the  above  noted  trophic 
influence  of  the  neuron  cell  on  its  own  processes,  there  are  influ- 
ences constantly  ascending  and  descending  peripheral  nerves  which 
are  essential  for  the  proper  nutrition,  growth  and  decay  of  the 
structures  which,  in  their  ordinary  functions,  are  under  the  control 
of  the  nerves  distributed  to  them — muscles,  for  instance,  or  sensory 
end  organs,  glands,  etc. — and  there  is  a  certain  amount  of  evidence 
to  show  that  these  influences  are  something  active,  liable  to  excess 
or  perversion,  as  well  as  absence,  for  it  is  found  that  irritation  or 
inflammation  of  nerve  structures  is  more  efl'ectual  in  producing 
destruction  or  degenerative  effects  than  is  mere  section  of  a  nerve 
trunk.  Illustrations  of  trophic  changes  will  be  noted  presently 
{vide  p.  266). 

E. — Special  Sense  Nerve  Phenomena  and  Mental  Processes. — These 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  255 

will  be  noted  when   the  brain   is  under  consideration.     We   may 
here  merely  mention — 


Sight      ^  . ,,     ^     ^. 

Hearing-  ^    .  And  in  disease  may  be  increased, 

°  1  prnitv  in  .  ...... 


Taste      r       111  perverted,  or  diminished. 

Smell     '       '^'^^*- 

Spinal  Cord. — To  enumerate  in  detail  the  functions  of  the 
cord  would  in  large  measure  be  to  repeat  what  we  have  said  on 
peripheral  nerves.  Its  cells  are  constantly  engaged  in  the  task  of 
superintending  the  nutrition  of  peripheral  nerves  and  other  struc- 
tures, as  well  as  of  intracordal  fibres  or  neurons,  as  has  already 
been  noted.  The  principal  function  of  the  cord,  as  a  whole,  is  to 
act  as  a  sort  of  subordinate  office  to  the  brain's  head  office,  and  by 
its  complexes  of  neurons  to  arrange  and  co-ordinate  impulses 
passing  through  it.  Thus  it  is  the  final  manager  of  efferent 
impulses  to  voluntary  muscles  arranging  their  order ;  it  is  the 
primary  manager  of  afferent  impressions,  enabling  our  minds  to 
become  precisely  and  accurately  conscious  of  our  environment ; 
and  lastly,  it  possesses  innumerable  mechanisms  for  the  perform- 
ance of  reflex  functions  of  all  descriptions  :  and  these  may  (a)  be 
performed  entirely  by  the  cord  without  notification  to  the  sensorium, 
or  (^)  cause  such  notification  so  that  we  perceive  the  reflex,  but  (c) 
they  are  always  liable  to  control  from  the  head  office  of  the  brain 
under  all  circumstances. 

Brain,  or  Encephalon. — As  the  seat  of  what  is  termed  the 
mind,  the  encephalon  remains  the  supreme  governor  and  controller 
of  every  process  going  on  in  the  body.  It  is  the  head  office  to 
which  all  information  from  every  part  must  be  sent,  whether  we 
are  conscious  of  such  information  or  not,  and  it  retains  to  itself 
the  power  to  intervene  in  and  control  everything,  but  allows 
generally  to  the  cord  a  very  large  measure  of  home  rule  in  those 
processes  which  are  mainly  concerned  in  the  mere  sustentation  of 
the  animal  framework. 

Having  thus  considered  anatomical  structure  and  physiological 
function  as  separate  entities,  we  have  now  to  associate  the  two  into 
mechanisms  for  purposes.  This,  even  in  the  peripheral  nerves,  is 
not  always  a  matter  of  mathematical  precision;  in  the  cord  the 
difficulties  become  much  greater,  while  in  the  brain  they  are  as 
yet  insurmountable  except  in  a  few  special  cases,  and  in  a  most 
general  manner.  We  shall  arrive  at  the  most  available  certainty 
\\ith  greatest  clearness  by  taking  functions  and  tracing  their  path- 


256  DIFFERENTIAL  DIAGNOSIS  chap. 

ways ;  the  following  tables  are  apparently  reliable  as  far  as  our 
present  knowledge  goes,  but  being  based  upon  clinical  experience 
and  experiment,  are  liable  to  some  alteration  as  our  knowledge 
grows  in  exactitude. 

Motor  Tracts  or  Pathways  of  Voluntary  Muscular 

Movements 

The  nerve  impulses  are  centrifugal ;  so,  taking  the  same  course, 
we  have — 

1.  Highest  volitional,  or  will  centres  of  doubtful  locality,  prob- 

ably (according  to  Hughlings  Jackson)  the  cortex  of  the 
frontal  lobes. 

2.  Rolandic  region  of  cortex. 

3.  Corona  radiata. 

4.  Anterior  two-thirds  of  posterior  limb  of  internal  capsule. 

5.  Pyramidal  tracts — 

{a)  In  crura  cerebri. 

{d)  In  pons. 

{c)  In  medulla  (including  the  decussation). 

{d)  In  cord  (crossed  and  direct). 

6.  Cells  of  anterior  cornua. 

7.  Peripheral  motor  nerves. 

8.  End  plates. 

9.  Muscles. 

In  any  given  voluntary  movement  the  parts  played  by  these 
various  structures  are  as  follows  : — 

In  (i). — The  wish  starts  by  psychological  processes  or  influ- 
ences from  without,  and  takes  a  less  amorphic  shape  as  nerve  im- 
pulses, which  pass  along  the  processes  of  the  neurons  concerned ; 
by  dendritic  synapses  these  impulses  are  transmitted  or  passed  on 
to  the  neurons  of  the  rolandic  region. 

In  (2). — These  physical  impulses  are  marshalled  and  co-ordinated 
in  a  manner  that  may  be  compared  to  the  first  sorting  of  letters  at 
the  General  Post  Office  into  those  for  each  sub-district  or  "route," 
and  just  as  by  arrangement  letters  can  be  sent  by  an  alternative 
route,  when  one  is  blocked,  with  slight  resultant  confusion  in  their 
delivery,  so  by  the  dendritic  synapses  of  innumerable  cortical 
neurons  can  these  impulses  be  transmitted  by  other  than  the  usual 
path,  with  resultant  delay  or  disturbance  in  movement.     Herein  lies 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  257 

the  commencement  of  the  explanation  of  the  common  statement 
that  "  Movements  and  not  muscles  are  represented  in  the  cerebral 
cortex  (and  cord)."  Each  neuron  of  the  rolandic  cortex  has  to 
share  in  many  movements,  but  never  completely  causes  one ;  hence 
slight  cortical  damage  is  likely  to  impair  many  movements,  but  not 
absolutely  to  paralyse  any. 

From  (2)  impulses  pass  through  (3),  (4),  and  (5)  in  a  compara- 
tively simple  manner  along  the  neuraxons,  and  break  on  the 
complicated  synapses  of  their  terminals  with  the  dendritic  com- 
mencements of  (6). 

In  (6),  \Yith  its  connections,  goes  on  the  final  sorting  of  impulses 
for  delivery  along  the  neuraxons  of  the  appropriate  members  of 
(7);  thus  is  completed  the  explanation  of  the  statement  inserted 
above  relative  to  movements  rather  than  muscles  being  represented 
in  brain  and  cord. 

Along  (7)  messages  are  carried  again  in  a  very  simple  manner 
to  reach  (8)  and  (9),  and  produce  in  them  appropriate  reaction. 

For  clinical  diagnosis  it  is  important  to  note  the  absolute  inde- 
pendence of  the  nutrition  and  life  of  the  neurons  of  (i),  or  level  A, 
of  (2)  to  (5),  or  level  B,  and  of  (6)  to  (9),  or  level  C.  A  lesion  of 
destructive  character  in  level  A  leaves  the  mechanisms  of  levels  B 
and  C,  qua  a  piece  of  machinery,  quite  untouched  and  ready  to 
start  and  carry  out  co  -  ordinate  movements,  provided  only  that 
impulses  can  reach  them  somehow;  and,  similarly,  B  and  C  are  nutri- 
tionally quite  independent ;  hence  we  find  at  the  bedside  that  a 
paralysis  due  to  lesion  in  level  C  is  characterised  by  the  flaccidity 
with  rapid  wasting  of  the  affected  muscles,  and  probably  other 
trophic  disturbances  of  the  skin  and  its  annexes.  A  paralysis  due  to 
a  lesion  in  levels  B  or  A  is  characterised  by  retention  of  the  tone  and 
of  volume  of  the  affected  muscles,  and  absence  of  trophic  disturb- 
ance of  other  structures. 

Sensory  Tracts  or  Pathways  of  Afferent  Impressions 

from  without 

These  impulses  are  centripetal,  and  hence  we  begin  with — 

1.  Peripheral  sensitised  end  organs  in  skin,  muscle,  or  special 
•  sense  mechanisms  (these  are  the  best  understood  clini- 
cally and  microscopically,  but  analogous  nerve  structures 
must  exist  in  every  tissue  and  gland  of  the  body). 

2.  Sensory  nerves  of  descriptive  anatomy. 

s 


2  58  DIFFERENTIAL  DIAGNOSIS  chap. 

3.  Cells  in  the  ganglia  on  the  posterior  roots. 

4.  Posterior  root  of  spinal  nerve. 

5.  Posterior    columns    of   cord,   external  and  internal,    and 

probably  also  Gowers'  antero-lateral  tract,  and  the  direct 
cerebellar  tracts. 

6.  Cells  in  funiculi  gracilis,  cuneatus,  and  rolandi,  and  also 

Clarke's  column. 

7.  Cells  and  fibres  in  formatio  reticularis  and  fillet  of  medulla 

and  pons,  tegmentum  of  crus  cerebri,  inferior  peduncle 
of  cerebellum,  and  the  cortex  of  both  cerebrum  and 
cerebellum. 

With  regard  to  the  part  played  by  these  various  structures  in 
the  perception  of  an  external  stimulus,  we  are  very  much  more  in 
the  dark  than  is  the  case  with  the  corresponding  motor  tracts ;  but 
the  following  statements  would  appear  to  be  justified : — 

In  (i)  the  external  impulse,  whether  of  touch,  temperature,  pain, 
etc.,  is  received  and  converted  into  what  we  can  only  call  a  common 
nerve  impulse,  which  is  then  carried  by  way  of  (2),  (4),  and  (5),  as 
along  telegraph  wires,  until  it  breaks  on  the  dendritic  synapses  of  the 
terminals  of  these,  and  thus  can  impress  itself  in  some  way  on  the 
terminals  of  the  neurons  in  (6)  and  (7).  It  is  commonly  assumed 
and  universally  accepted  as  a  legitimate  deduction  from  experiment 
and  clinical  evidence  that  Nos.  i,  2,  3,  4,  and  5  form  a  lowest  level 
or  neuron  complex,  corresponding  to  the  lowest  level  on  the  motor 
side,  and  that  this  lowest  level  is  dependent  for  its  nutrition  on 
No.  3  ;  the  injury  or  destruction  of  which  results  in  corresponding 
degeneration  or  destruction  of  the  whole  level.  But  after  we  leave 
this  level  precise  knowledge  ceases,  and  speculation  reigns  as  to 
the  number  of  serial  neuron  levels  and  as  to  the  exact  paths  by 
which  impulses  reach  the  sensorium,  and  even  as  to  the  locality  of 
the  sensorium.  And,  again,  as  regards  co-ordination  of,  or  judgments 
upon  external  impressions,  we  only  know  that  disease  of  the  lowest 
level  (as  in  tabes  dorsalis)  leads  to  great  perversion  of  them ;  e.g. 
a  touch  is  referred  to  a  totally  wrong  spot,  but .  we  do  not  know 
whether  this  lowest  level  is  the  only  co-ordinator  of  afferent  impres- 
sions, or  even  if  it  is  the  chief  one. 

Reflex  Paths 

So  far  as  is  known,  there  are  no  special  paths  reserved  entirely 
for  reflexes;  the  impulses  travel  by  the  ordinary  sensory  and  motor 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


259 


nerves.  We  may,  however,  discuss  a  few  points  in  this  connection. 
For  a  reflex  phenomenon  we  require  a  chain  of  structures  which 
we  may  thus  tabulate  : — 


A  sentient  receptive 
surface  or  end 
organ  on  which 
the  stimulus  may 
act. 

An  afferent  nerve. 

A  central  connection 
of  afferent  and 
efferent  mechan- 
isms. 


An  efferent  nerve. 


A  terminal  organ  to 
exhibit  the  reflex, 
whatever  its 
nature. 


Skin  or  external  surface  in  the  experimental 
class. 

Mucous  membrane  or  epithelial  cells  in  visceral 
class. 

Tissue  elements  (?)  in  vasomotor  class. 

The  ordinary  afferent  nerves  of  the  organ  or  area 
in  question. 

This,  so  far  as  we  can  judge,  is  not  an  organic  or 
structural  connection,  but  merely  the  functional 
synapses  of  the  dendritic  terminals  of  the  re- 
spective sensory  and  motor  neurons  in  the 
central  system,  allowing  a  transmission  of 
impulse. 

The  motor  nerves  of  voluntary  or  involuntary 
muscles,  corresponding  to  the  class  of  reflex  in 
question  ;  and  nerves  carrying  efferent  im- 
pulses for  other  organs. 

Voluntary  muscles  in  Class  I. 

Involuntary  muscles,  fibres,  and  epithelial  cells 
of  glands  of  viscera  in  Class  II. 

Involuntary  muscle  fibre  in  arterial  coats  in  Class 
III. 


For  the  reflex  to  take  place  it  is  essential  that  this  chain  should 
be  complete  in  each  link,  and  that  there  should  be  no  strong  in- 
hibitory influence  at  work  capable  of  stopping  the  reflex. 

Class  A. — The  true  or  superficial  reflexes  m.ay  occur  from  any 
area  of  skin  or  from  the  conjunctiva.  Those  most  commonly  looked 
for  are  : — 

Plantar,  involving  health  of  i,  2,  and  3  sacral  nerves  and  connections. 
Cremasteric    „  „  i,  2,  and  3  lumbar  „  „ 

Abdominal      „  ,,  8  to  12  dorsal  and  i  lumbar   „       „ 

Thoracic  „  „  i  to  8  dorsal  „       „ 

Conjunctival   „  „  5  and  7  cranial  „       „ 


but  in  special  cases  many  others  are  looked  for  as  indications  of 
health  or  disease  of  specific  nerves  and  segment  of  the  cord. 

Of  the  so-called  deep  or  tendon  reflexes  at  knee,  elbow,  wrist, 
etc.,  we  know  that  the  path  for  them  must,  in  some  of  its 
details,  be  different   from  that  of  the  superficial  ones,  for  the  two 


26o 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


can  vary  independently  of  one  another  in  degree ;  the  knee  jerk, 
for  example,  is  often  absent,  while  the  superficial  reflexes  of  the  leg 
are  still  obtainable.  The  knee  jerk  has  been  more  fully  studied 
than  any  of  them,  and  about  it  we  may  make  the  following  state- 
ments, with  deductions  : — 

It  requires  for  its  production — 

(i)  A  certain   degree  of  myotatic  irritability  (Gowers)  in  the 

quadriceps  extensor  muscle. 
(2)  The  integrity  of  the  third  and  fourth  lumbar  nerves,  and 

their  synapses  in  the  cord. 

It  is  capable  of  being  modified  by  influences  from  the  en- 
cephalon,  which  influences  are  found  to  travel  by  the  pyramidal  tracts 
of  fibres,  and  are  believed  to  be  of  two  kinds :  {a)  restraining  from 
the  cerebrum ;  {d)  reinforcing  from  the  cerebellum  (Jackson). 

As  deductions  from  these  premises — 

{a)   Diminished  cerebral  control. 

{b)   Increased  cerebellar  influence. 

{c)   Increased    irritability   in    some   link    of    the 

spinal  and  peripheral  chain. 
{a)   Increased  cerebral  control. 
{I?)   Diminished  cerebellar  influence. 
{c)  Diminished  irritability  (or  break)  in  some  link 

of  the  spinal  and  peripheral  chain. 

When  the  knee  jerk  is  found  to  be  materially  altered  in  character 
from  an  average  expected  normal,  we  should  try  and  estimate 
which  of  these  influences  is  at  work.  The  common  clinical  examples 
are : — 

Indicated  by 

Apoplectic    seizure     of 

ordinary  type. 


Increased  knee  jerk 
means 


Diminished  or  ab- 
sent knee  jerk 
means 


Knee  jerks  increased 
from  cause  (a). 


of 


Paralysing    lesion 
rolandic    cortex,    or 
internal  capsule. 

Lateral    sclerosis     pri- 
mary. 


Old  transverse  myelitis 
above  lumbar  en- 
largement, causing, 
e.g.,  lateral  sclerosis 
of  lower  part  of 
cord. 


Chronic  history  of  in- 
creasing weakness 
and  jerkiness  in 
walking. 

History  of  acute  para- 
plegia. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


261 


From  cause  {b). 


From  cause  (r). 

Knee  jerk  diminished 
or  absent  from 
cause  {a). 


From  {b). 


From  {c). 


Occasionally  apparent- 
ly in  cerebellar  tu- 
mour, causing  more 
irritation  than  de- 
struction. 

Peripheral  neuritis  in 
early  stages. 

Occasionally  apparent- 
ly in  tumour  of  cere- 
brum. 

Meningitis,  vertical  and 
even  basic. 

In  shock  their  absence 
is  probably  partly 
thus  explained;  gen- 
eral paralysis  of  in- 
sane in  later  stages. 

Occasionally  apparent- 
ly in  abscess  and 
tumours  that  have 
destroyed  some  parts 
of  cerebellum. 

Peripheral  neuritiSjlater 
stages,  acute  or 
chronic  anterior  po- 
liomyelitis. 

Tabes  dorsalis. 

Pseudo  -  hypertrophic 

paralysis. 
Myelitis       of      lumbar 

region. 


Indicated  by 

Headache,      vomiting, 
and  optic  neuritis. 


Pins  and   needles,  and 

weakness. 
Headache,      vomiting, 

optic    neuritis,    etc., 

Jacksonian  epilepsy. 
Pyrexia    with    cerebral 

symptoms. 
Mental  features. 


As  above. 


Rapid  or  chronic  wast- 
ing of  muscles  with 
R.D. 

Lightning  pains;  Arg}'ll 
Robertson  pupils,  etc. 

IMethod  of  getting  up 
from  the  floor. 

Acute  paraplegia. 


In  some  of  the  above  cases  the  meaning  of  the  alteration  is  fairly 
clear  and  definite,  but  it  must  be  confessed  that  in  tumours  and  in 
inflammation  within  the  cranium  neither  the  result  nor  its  cause  is 
always  very  obvious.  In  epilepsy,  again,  the  frequent  absence,  and 
in  general  paralysis  of  the  insane  the  frequent  exaggeration,  are  not  at 
once  readily  explicable  ;  in  hysteria  the  knee  jerks  are  very  variable, 
and  I  have,  I  believe,  found  them  absent  in  an  otherwise  perfectly 
healthy  individual. 

Class  B. — Visceral.  For  the  bladder  and  rectum  (it  would 
seem  probable  also  that  the  rest  of  the  alimentary  tract  and  other 


262 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


viscera  are  under  similar  control  by  means  of  the  appropriate  sym- 
pathetic and  ordinary  nerves)  it  is  assumed,  with  great  probability, 


I^olanpic  vtotor 
area 


Voluntary 
abdovi. 
muscles 


Diagram  to  represent  nerve  impulses  concerned  in  normal  micturition. 
that  in  the  lumbar  enlargement  of  the  cord  the  synapses  of  the 
sensory  and  motor  neurons  of  the  lower  sacral  nerves  (probably)  are 
so   arranged    that   afferent   impulses,  started  by  the   condition   or 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  263 

contents  of  the  viscus,  on  reaching  the  cord  can,  and  do  in  health, 
diverge  in  three  directions :  one  impulse  or  message  goes  by  cither 
the  posterior  or  anterolateral  ascending  columns  of  the  cord  to  the 
sensorium,  and  there  produces  by  appropriate  synapses  a  wish  to 
micturate  or  defcecate ;  following  this  message  to  its  termination, 
and  supposing  the  nervous  system  is  quite  intact,  the  desire  can 
result  in  restraint  of  the  act  or  in  the  act  itself,  according  as  circum- 
stances of  a  social  nature  are  unfavourable  or  the  reverse  ;  the  former 
being  one  illustration  of  inhibition  {vide  p.  267).  In  either  case 
the  messages  (though  of  different  import)  pass  down  the  pyramidal 
tracts  (?)  to  the  appropriate  cells  of  the  anterior  cornua,  and  thence 
by  peripheral  neurons  (i)  to  the  voluntary  abdominal  muscles,  (2)  to 
the  sphincter,  and  (3)  to  the  detrusor  musculature  of  the  bladder,  in- 
fluencing them  in  a  manner  appropriate  to  the  control  or  permission 
of  the  act.  The  second  and  third  divisions  of  the  afferent  message 
are,  as  it  were,  short  circuited,  passing  simply  into  the  cord  by  the 
posterior  roots  and  immediately  becoming  transmitted  by  synapses 
to  the  efferent  neurons  controlling  the  sphincter  and  detrusor 
muscles  of  the  bladder,  and  causing  action  or  inaction  of  those 
muscles  respectively.  It  is  by  this  short  circuit  that  micturition  and 
defaecation  are  provided  for  in  the  absence  of  consciousness.  A 
diagram  shows  this  somewhat  complicated  description  very  simply. 

Theoretically,  then,  it  is  possible  for  the  acts  to  be  interfered  with 
by  lesions  in  any  part  of  this  course,  but  clinically  such  interferences 
may  be  reduced  to  one  of  four  categories,  which,  with  the  possible 
explanation  in  each  case,  may  be  thus  stated : — 

I.  Retention  of  urine,  distension  of  the  bladder,  with  overflow 
and  consequent  constant  dribbling.  This  is  perhaps  the  commonest 
form,  and  is  found  under  many  widely  different  clinical  circum- 
stances. Its  possibility  is  due  essentially  to  the  fact  that  the 
sphincter  fibres  of  the  bladder  are  more  powerful  than  the  detrusor 
fibres.     It  occurs  in — 

{a)  Parturition,    es-  Probably  then  due  to  a  spasm  of  the  sphincter, 

pecially    primi-  produced  locally  by  irritative   prolonged   pres- 

parae.  sure  of  foetus. 

{p)   Operative     pro-  Probably  due  to  intense  reflex  stimulus  of  unusual 

cedures     about  character  through  tinusiial  channels,  leading  to 

perineum,  etc.  spasm  of  sphincter. 

[c)  Tabes      dorsalis  Probably  due  to  an  inability  of  afferent  messages 

occasionally.  to   reach   the   efferent  neurons   with    sufficient 
energy. 


264 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


{d)  Senile  and  other 
mental  condi- 
tions, especially 
so-called  hy- 
sterical. 

[e)  Enlarged  pro- 
state and  stric- 
ture, etc. 


Probably  the  original  fault  lay  with  highest  will 
centres  in  checking  the  voluntary  act  from 
deliberate  motive ;  this  was  followed  by  blunting 
of  sensorium,  while  the  sphincter  still  retained 
its  ascendency  in  physical  power. 

Difficulties  probably  purely  mechanical  and  not 
nervous  at  all,  except  that  habit  blunts  the 
sensory  terminals  in  the  bladder. 


2.  Complete  incontinence,  bladder  never  full,  urine  constantly 
dribbling  as  fast  as  it  reaches  the  bladder.  Indicates  essentially  a 
paralysis  of  the  sphincter  fibres.  This  form  is  rarely  found  except 
in — 

Acute   transverse  Due  to  destruction  of  the  motor  efferent  neurons, 
myelitis  of  lum-         and  consequent  absolute  sphincter  paralysis,  so 
bar      enlarge  -         that  gravity  causes  the  escape  of  urine, 
ment. 

It  is  a  curious,  but  very  important  fact,  that  such  absolute  in- 
continence is  never  found  in  purely  functional  peripheral  troubles, 
and  only  as  the  rarest  of  curiosities  even  in  organic  definite 
peripheral  neuritis. 

3.  A  co-ordinated  more  or  less  normally  complete  emptying  of 
the  bladder  without  the  intervention  of  the  will  or  of  consciousness. 
The  occurrence  of  this  form  essentially  indicates  that  the  lumbar 
(sphincter  and  detrusor)  centres  are  intact  with  all  their  reflex 
mechanisms,  and  proves  to  a  demonstration  that  the  higher  centres 
are  not  essential  for  the  act,  but  that  the  lumbar  cord  is  quite 
competent  when  necessary  to  control  the  entire  proceeding.  It 
occurs  pretty  frequently,  e.g.  in  : — 


{a)  Nocturnal  incon- 
tinence in  chil- 
dren (enuresis). 

(Ji)  Transverse  mye- 
litis above  the 
lumbar  enlarge- 
ment. 

{c)  Tumours  and 
other  forms  of 
pressure,  caus- 
ing paraplegia. 


May  indicate  unusually  powerful  stimuli  (stone, 
hyperacidity,  etc.),  or  undue  irritability  of  the 
local  nervous  mechanism. 

Here  it  is  a  localising  indication  of  the  position 
of  the  lesion,  and  is  of  considerable  value  as 
indicating  that  the  mischief  has  not  reached 
the  lumbar  cord. 

Again  a  localising  symptom  of  some  importance. 


4.  Slighter  degrees  of  interference  with  co-ordinate  micturition. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


265 


These  form  rather  a  heterogeneous  group  of  cases  in  their  outward 
manifestations.      It  includes  : — 


Probably  due  to  irregularity  in  arrangement  and 
arrival  of  reflex  messages  on  the  afferent  side. 


Probably  the  messages  on  the  afferent  side  are 
abnormal  in  their  meaning ;  possibly  also  there 
may  be  local  irritation  of  sphincter,  so  that 
distension  with  overflow  may  result. 

Indicates  merely  a  little  weakness  of  sphincter. 


Probably  only  indicate  the  great  intensity  of 
natural  stimuli,  the  nervous  mechanism  being 
intact. 


id)  Tabes  dorsalis 
with  what  is 
termed  stam- 
mering blad- 
der ;  may  be 
present  in  other 
forms  of  sclero- 
sis of  cord. 

{p)  Temporary  re- 
tention in  spas- 
modic stricture, 
stone,  etc. 

{c)  Discharge  of  ur- 
ine on  cough- 
ing, especially 
in  women. 

id)  Strangury  and 
frequent  mictu- 
rition of  cystitis 
or  of  enlarged 
prostate  at 
night. 

Although  we  have  thus  dealt  at  length  with  the  bladder  only, 
it  is  extremely  probable  that  defaecation  is  under  precisely  similar 
control,  and  worked  by  precisely  similar  mechanism  j  but  the 
clinical  manifestations  of  its  pathological  performance  are  not  so 
marked,  nor  so  easily  followed  in  detail.  This  is  no  doubt  due  in 
part  to  the  greater  capacity  and  distensibility  of  the  colon,  which 
acts  towards  the  sphincter  ani,  like  the  body  of  the  bladder  to  its 
sphincter ;  but  chiefly  to  the  fact  that  the  bladder  is  being  constantly 
filled  with  a  fluid  secretion,  while  the  rectum  is  being  intermittently 
filled  with  a  (more  or  less)  solid  material;  a  few  doses  of  saline  aperient 
will  render  the  likenesses  in  action  more  apparent. 

Class  C. — Vasomotor  reflexes.  Of  the  nerves  and  paths  by 
which  these  pass  we  are  profoundly  ignorant,  except  that  they  seem 
to  run  in  the  so-called  sympathetic  chain,  and  to  pass  to  and  from 
the  cord  with  the  anterior  roots.  We  recognise  the  loss  of  vaso- 
motor control  in  paralysed  limbs  and  under  many  other  conditions, 
but  we  are  not  able  to  make  much  clinical  use  of  our  observations 
as  regards  localising  indications. 


266        '  DIFFERENTIAL  DIAGNOSIS  chap. 

From  the  fact  that  all  reflexes  may  in  health  or  disease  be 
attended  with  sensory  perception  of  their  occurrence,  it  follows 
as  a  legitimate,  and  indeed  inevitable  deduction,  that  the  path  of  the 
afferent  impulse  must  have  at  least  two  dendritic  connections  in  the 
spinal  cord  or  central  system :  one  with  the  appropriate  motor 
neuron,  and  the  other  with  those  neurons  which  ultimately  conduct 
an  impression  to  the  sensorium.  An  anatomical  basis  has  been 
discovered  for  this  deduction  in  the  division  of  all  afferent  nerves 
into  two  branches — one  going  towards  motor  neurons,  and  one 
continuing  in  the  direction  of  the  sensorium. 

Seat  and  Paths  of  Trophic  Influences 

But  little  can  be  said  on  this  head  beyond  what  has  already 
been  noted  in  the  general  description  of  a  neuron  and  the  functions 
of  its  component  parts.  It  would  appear  that  for  the  perfect  nutri- 
tion of  all  structures  they  must  have  a  perfect  connection  with  a  (at 
least  one,  and  probably  several)  neuron  cell,  the  physiological  health 
of  which  they  equally  enjoy ;  failing  with  it,  and  recuperating  too 
with  it.  Obviously  the  most  simple  and  uncomplicated  evidence  of 
this  probable  connection  is  most  likely  to  be  found  and  established 
in  the  case  of  the  peripheral  neurons  of  the  limbs,  the  dendritic 
synapses  and  relationships  of  which  are  fairly  well  understood  ;  and 
the  following  clinical  examples  go  far  to  establishing  the  general 
proof  of  the  theory  : — 

1.  The  rapid  atrophy  of  the  corresponding  motor  nerves  and 
muscles  (or  parts  of  muscles)  after  complete  destruction  of  all  (or 
some)  of  the  cells  of  the  anterior  cornua. 

2.  The  defective  growth  of  all  parts  of  a  limb  that  has  been  in 
childhood  severely  paralysed  by  anterior  poliomyelitis. 

3.  The  changes  in  the  skin  and  annexa  when  the  sensory  nerves 
or  cells  on  the  posterior  roots  are  damaged. 

4.  The  mysteriously  rapid  onset  of  bed  sores  from  very 
slight  causes  (pressure,  warmth,  etc.)  in  many  cases  of  acute 
myelitis. 

5.  The  equally  malignant  cystitis  and  renal  trouble  that  so 
frequently  accelerates  or  causes  death  in  similar  cases  of  myelitis, 
notwithstanding  most  rigorous  asepticism  in  artificial  emptying  of 
the  bladder. 

6.  Certain  very  suggestive  dystrophies  after  experimental  divi- 
sion of  nerves,  e.g.  the  fifth  cranial,  etc. 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  267 


Special  Sense  Tracts 

The  olfactory,  optic,  auditory,  and  glosso-pharyngeal  nerves 
require  only  to  be  mentioned  here.  Their  connections  will  be  better 
studied  when  dealing  with  the  principles  of  brain  localisation  {vide 
Cranial  Nerves,  p.  303). 

These  facts  of  anatomy  and  associated  function  form  the  main 
foundation  upon  which  are  laid  the  principles  of  differential 
diagnosis  of  nervous  diseases ;  but  before  proceeding  to  construct 
tables  from  them,  there  are  a  few  general  points  and  terms  to  which 
attention  must  first  be  directed. 

Inhibition  and  Interference 

By  these  terms  are  understood  the  power  which  one  neuron  or 
group  of  neurons  possesses  of  so  influencing  another  neuron  or 
group  as  to  check  or  interfere  with  in  any  direction  the  function 
which  the  second  mechanism  intrinsically  possesses.  This  power 
may  be  exercised  either  voluntarily  through  the  will,  of  which  our 
daily  actions  are  almost  one  continuous  example,  or  it  may  be,  and 
probably  is,  the  inherent  function  of  large  numbers  of  neuron  com- 
plexes which  may  thus  act  without  any  effect  on  consciousness,  the 
most  constantly  occurring  clinical  example  of  which  is  the  hy- 
pothecated influence  of  the  cerebral  and  cerebellar  cortex  on  spinal 
reflexes  \  the  former  being  supposed  to  check  them,  the  latter  to 
increase  them. 

Inhibition  and  interference  constitute  almost  insuperable  diffi- 
culties in  the  w^ay  of  drawing  satisfactory  and  conclusive  deductions 
from  the  experimental  destruction  of  limited  areas  of  nerve  tissue  in 
cord  or  brain. 

Direct  and  Indirect  Symptoms 

By  direct  symptoms  are  understood  those  negative  or  positive 
morbid  phenomena,  directly  appreciable  by  the  observer,  which 
arise  as  the  direct  result  of  destruction  or  irritation  of  a  certain 
group  of  fibres  with  known  definite  function,  e.g.  blindness  from 
laceration  of  optic  nerve,  noises  from  irritation  of  the  auditory 
nerve,  paralysis  from  the  destruction  of  the  pyramidal  tracts,  etc. 

Indirect  symptoms,  as  the  term  is  used  clinically,  are  really  of 
two  kinds :  {a)  those  which  must  be  assumed  to  exist  as  the  plainest 
corollary  from  the  hypothesis  of  inhibition   and   interference,  and 


268  DIFFERENTIAL  DIAGNOSIS  chap. 

may  be  of  a  positive  or  negative  character,  e.g.  increased  knee 
jerk  from  destruction  of  brain  areas  ;  or  diminished  knee  jerk  from 
irritation  of  similar  areas ;  {f)  those  which  might  perhaps  be 
more  properly  spoken  of  as  temporary  symptoms,  in  that  they  are 
the  result  of  mere  increase  of  pressure  which  is  often  capable  of 
removal ;  examples  of  which  are  very  common  in  tumours  of  the 
brain  or  pons,  and  haemorrhage  anywhere  into  the  central  nervous 
system  or  its  containing  cavity.  These  pressure  symptoms  must  be 
allowed  to  subside  in  acute  (haemorrhagic  probably,  or  inflammatory) 
lesions  before  an  exact  diagnosis  is  possible ;  and  in  more  chronic 
cases  of  tumour  their  possible  presence  and  significance  must  be 
very  carefully  considered. 

Inco-ordination 

For  every  movement,  whether  voluntary  or  reflex,  at  least  two  (and 
often  many  more)  muscles  or  groups  of  muscle  fibres  are  called  into 
action ;  and  in  order  that  the  movement  may  be  co-ordinated 
these  several  muscles  must  all  act  in  harmonious  relationship  to 
each  other  (i)  in  time,  (2)  in  amount,  i.e.  if  one  of  the  muscles  con- 
cerned acts  out  of  its  turn,  or  with  a  force  disproportionate  to  that 
exerted  by  the  other  muscles  concerned,  the  movement  will  become 
disorderly,  inco-ordinate,  and  even  perhaps  inadequate  to  its  avowed 
object.  Now,  by  arguments  which  cannot  be  introduced  here,  it  is 
proved  that  afferent  impulses  from  the  muscles  to  the  cerebrum  and 
cerebellum  (not  necessarily,  and  in  fact  not  usually,  causing  a  con- 
scious perception)  are  as  important  for  co-ordination  as  are  the 
motor  or  efferent  impulses  to  the  muscles ;  and  in  fact  clinical 
experience  almost  allows  the  deduction  that  if  inco-ordination  of 
voluntary  movement  be  present  there  is  a  lesion  of  afferent  tracts 
either  of  the  ordinary  class  or  of  the  special  senses ;  disseminated 
sclerosis  being  almost  the  only  exception,  and  even  here  it  is 
assumed  rather  than  proved  that  the  inco-ordination  arises  from 
delay  in  the  transmission  of  motor,  and  not  afferent  impulses.  It  is 
more  commonly  complained  of  in  walking  (giddiness  or  stumbling) 
than  in  other  actions,  because  this  requires  very  complicated  and 
delicate  adjustments  of  very  many  muscles,  but  clinical  examination 
very  frequently  reveals  much  that  is  not  complained  of  by  the 
patient.  The  following  are  the  principal  clinical  causes  of  inco- 
ordination, and  the  leading  indications  pointing  to  the  probable 
diagnosis. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


269 


Cause. 
Peripheral  neuritis. 


Affections  of  pos- 
terior columns 
(?  of  antero-lateral 
ascending  tracts 
too). 

Cerebellar  or  cere- 
bral disease. 


False  optical  impres- 
sions. 


Alcohol  or  other 
general  action  on 
the  sensorium. 


Leading  Features. 

"Pins  and  needles,"  and  other  sensation  abnormali- 
ties and  weakness  complained  of;  skin  dystrophy 
or  anaesthetic  patches  ;  knee  jerks  increased  or 
absent  ;  inco-ordination  made  worse  by  closing 
the  eyes. 

Histor}'-  of  lightning  pains  ;  knee  jerks  absent  ; 
inco-ordination  worse  on  closing  the  eyes. 


Very  possibly  severe  headaches  or  optic  neuritis 
if  a  tumour  ;  if  other  trouble  of  chronic  nature 
history  clears  up  the  cause  ;  closure  of  eyes 
not  likely  to  make  matters  worse,  because  inco- 
ordination is  central. 

A  squint,  found  by  appropriate  tests  ;  inco-ordina- 
tion iinproved  by  closure  of  the  affected  eye, 
or  of  one  if  both  are  affected,  because  this  at 
once  stops  the  wrong  perceptions. 

History  generally  obvious  ;  there  are  also  mental 
alterations,  marked  in  directions  other  than 
that  of  co-ordination  of  movement  \  effect  of 
closure  of  eyes  variable. 


Reaction  of  Degeneration 

By  this  term  is  understood  those  peculiar  changes  in  the  elec- 
trical reactions  of  a  77iuscle  which  are  produced  in  it  by  the  death  of 
the  peripheral  neurons  distributed  to  it.  They  are  of  two  kinds — 
quantitative  and  qualitative.  The  essential  points  to  be  remembered 
about  R.D.  are  : — 


I. 


It  is  a  phenomenon  of  muscle  only  (nerves  simply  lose  irri- 
tability rapidly  after  severance  from  their  nutritive  cells). 

It  always  indicates  that  the  peripheral  neuron  going  to  the 
muscle  fibre  is  dead  or  dying. 

It  is  a  phenomenon  exhibited  by  each  muscle  fibril,  and 
consequently  is  only  exhibited  in  a  simple  and  typical 
manner  when  at  least  a  large  majority  of  the  individual 
•  neurons  going  to  a  gross  anatomical  muscle  are  affected  ; 
thus  is  explained  its  common  absence  in  typical  form  in 
some  cases  of  progressive  muscular  atrophy,  and  other 
slowly  progressive  neuron  destructions. 


2  70  DIFFERENTIAL  DIAGNOSIS  chap. 

4.   The  quantitative  element  may  be  thus  represented : — 
1st  Period.  2nd  Period.  3rd  Period.  4th  Period. 


c  - 

C  normal  or  + 

C   +    + 

C-o 

F  - 

F  - 

F    -    0 

F-o 

where  C  and  F  represent  irritability  to  the  constant  and 
Faradic  currents  respectively,  and  period  roughly  represents 
a  week  or  ten  days  or  less. 
The  qualitative  element  is  that — 

fKCC.  fACC. 


The  natural        A.C.C.  ,  K.C.C. 

A  O  r  becomes 


order  of 


K.O.C. 


K.O.C. 
A.O.C. 


during  the  first  two  or  three  periods,  but  when  C  and  F 
both  become  diminished — as  between  the  3rd  and  4th 
periods — the  above  change  may  occur  without  our  being 
able  to  make  the  definite  statement  that  R.D.  is  present. 


Section  II. — Diseases  of  Nervous  System 

Proceeding  now  to  consider  pathological  diagnosis,  it  will  conduce 
to  clearer  views  of  analysis  if  we  insert  a — 

Tabular  View  of  the  Causes  of  Diseases  of  the 
Nervous  System 

1 .  Traumatism. 

Recent.      History  obvious. 

Past.  May  lead   to   secondary  changes   of  sclerosing  or  neo- 

plastic nature. 

2.  Vascular  Disturbances^  with  Probable  Post-Mortem  Eviaence. 

A.    Inflammation.! 

(I)  Primary    of    nerve -|  Cerebritis. 

Structures,      with  I  ,^     ,.  .       r        ■, 
•  J      J  >  Myehtis  of  cord, 

rapid     deg-enera-  i  ,.       .  . 
^.  J     S     •        \  Neuritis,  pohomyehtis,  etc. 

tion  and  softening,  y  '^  ^  ' 

*  The  term  "  inflammation"  is  used  here  as  the  most  convenient,  because  long- 
established,  to  express  the  fact  of  an  acute  and  very  rapid  destructive  degeneration 
of  neuron  cells  or  processes,  or  both,  which  may,  however,  and  often  does,  occux"  with- 
out very  obvious  changes  in  the  blood-vessels  of  the  area. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


271 


(2)  Primary  of  intersti- 
tial or  meningeal 
origin,  extending 
to  nerve  struc- 
tures. 

B.  Haemorrhage. 

C.  Plugging  of  a  Vessel. 

(i)   Embolic. 
(2)  Thrombotic. 

3.  Tumours. 

Malignant,  carcinoma  and 
sarcoma. 

Simple  connective  tissue  type. 

Tubercular. 

Syphilitic. 

Abscesses,  i.e.  cysts  of  inflam- 
matory origin. 

Cysts  of  non  -  inflammatory 
origin. 

4.  Scleroses. 

Primary. 


i  Meningitis. 
I  Perineuritis. 


Vascular  degeneration. 
Aneurysms. 
Septic  arteritis. 

From  cardiac  valves,  aorta,  etc. 
From        endarteritis        obliterans, 
syphilis,  tubercle,  etc. 


All    primarily   irritants,    and    later 
\      destructive    by    pressure   or    by 
invasion  of  nerve  fibres. 


Either  of  a  distinct   system,   e.g. 
pyramidal    tracts,   or    of   quasi- 
accidental  patches. 
Secondary.  Following    destruction    or  separa- 

tion of  processes  from  the 
neuron  cells  by  any  means 
whatever,  e.g.  lateral  sclerosis 
after  cerebral  destruction. 

5.  Nutritional  Disturbances. — A  group  of  cases  more  easily  com- 
prehended by  the  imagination  than  defined  in  words.  It  is  usually 
intended  to  include  hysterical  and  other  cases  in  which  recovery  is 
(usually)  complete  and  (not  unfrequently)  very  rapid.  They  probably 
all  have  as  their  essential  foundation  a  primary  lowering  of  the  vitality 
of  a  neuron,  with  loosening  of  its  synapses  with  other  neurons,  thus 
interfering  with  the  transmission  of  impulses.  It  is  obvious  that  if  this 
process  goes  beyond  a  mere  chemical  or  molecular  disturbance  the  case 
may  soon  have  to  be  put  in  some  organic  degenerative  group. 

Any  of  these  pathological  changes  77iay  occur  anywhere  through- 
out the  nervous  system,  but  each  one  has  its  seat  of  election,  and 
hence,  when  the  locality  of  a  lesion  in  any  case  is  settled,  we  are 
often  cariied  very  far  in  the  direction  of  a  diagnosis  of  its  nature, 


272 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


and  vice  versa.  The  history  of  the  onset  is  such  an  important  factor 
in  the  diagnosis  of  the  nature  of  a  nerve  lesion  as  to  necessitate 
the  insertion  of  the  following  table,  copied  from  Sir  W.  Gowers  : — 


Disease. 


Onset. 


Sudden, 


Acute        J  few  minutes, 

traumatism.    \    Acute, 

(^  few  hours  or  days. 

Sub-acute, 

one  to  six  weeks. 

Sub-chronic, 

,  six  weeks  to  six  months, 

growths.       I     ^, 
^  I     Chronic, 

over  six  months. 


Pressure 
and 


Disease. 

Vascular 
lesion. 


►     Inflammation. 


Degeneration    or 
scleroses. 


An  occasional  exception  may  occur,  the  most  important  of 
which  is  the  suddenness  with  which  tumours  may  now  and  again 
cause  symptoms  either  by  haemorrhage  taking  place  into  them  when 
otherwise  quiescent,  or  by  some  slight  mechanical  alteration  in  the 
relation  of  parts  when  tumour  is  present. 


Section  III. — Differential  Diagnosis  of  Nervous  Diseases 

With  this  introductory  outline  of  the  structure,  functions,  and 
general  phenomena  of  the  nervous  system,  and  of  its  disturbances, 
we  may  proceed  to  the  more  specialised  differential  diagnosis  of 
nervous  diseases. 

The  first  point  in  the  precise  diagnosis  of  an  apparently  nervous 
group  of  symptoms  must  be  the  determination  as  to  whether  the 
symptoms  are  primarily  and  essentially  caused  by  an  actual  lesion 
(organic  or  nutritional — Gowers)  of  the  nervous  system,  or  whether 
they  are  secondarily,  i.e.  purely  reflexly,  connected  therewith,  due  to 
pyrexia,  for  example,  or  local  disease  of  other  organs. 

To  exhaust  from  this  point  of  view  in  tabular  form  the  differen- 
tiation of  all  the  varied  phenomena  of  disease  would  be  confusing 
and  unpractical,  if  not  even  impossible,  considering  that  it  is  only 
through  our  nerve  structures  that  we  are  made  conscious  of,  and 
adapted  to,  all  the  variations  of  our  environment,  both  local  and 
general,  and  that  the  co-ordinate  or  harmonious  working  of  each 
and  every  organ  throughout  the  body  is  possible. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


273 


The  following  table,  then,  is  but  the  veriest  fragment  of  an  outline 
of  the  subject,  inserted  more  for  logical  completeness  of  the  ideal 
object  of  this  book  than  for  serious  practical  utility,  though  I  have 
endeavoured  to  make  it  serviceable  as  well. 


Chronic  and  Sub-Chronic  Symptom  Groups 


If  Caused  by  Essential  Affection  of 
Nervous  System. 

Absence  of  obvious  primary 
peripheral  local  disease  ;  es- 
pecially examine  blood  and 
urine  and  pelvic  organs. 
Motor  complaints  largely  in  the 
ascendent ;  weakness  and  loss 
of  power  in  limbs  or  unsteadi- 
ness ;  movement  or  its  loss 
rarely  associated  with  pain. 
Sensory  complaints  often  also 
prominent ;  usually  numbness 
or  parsesthesise,  if  painful  most 
likely  of  a  neuralgic,  i.e.  inter- 
mittent and  shooting  character, 
or  without  obvious  objective 
causation. 

Complaints  of  vague  alterations 
from  the  usual  harmonious  ease 
of  the  acts  of  micturition  and 
defaecation. 


5.  Insidious  onset,  very  variable 
progression,  and  unlimited  chro- 
nicity. 


6.  Reflexes  probably  altered. 


If  Secondarily  or  Reflexly  Nervous. 

:.  Such  disease  is  present;  cau- 
tio?i — secondary  trophic  lesions 
not  to  be  mistaken  for  pri- 
mary. 

;.  Such  complaints  absent,  except 
with  obvious  disease  of  muscles 
or  alteration  in  outline  of  joints 
or  limbs  :  gout,  rheumatism, 
epiphysitis,  etc. 

(.  Such  complaints  practically 
only  of  a  painful  nature,  and 
frequently  with  obvious  causa- 
tion, e.g.  chronic  pleurisy,  cold, 
abscesses,  etc. 


4.  Complaints  about  these  acts 
usually  of  a  straightforward 
difficulty  in  act,  or  definite 
alteration  in  frequency,  e.g. 
stricture,  enlarged  prostate, 
etc. 

5.  Onset  fairly  marked,   progress 

more  uniform  and  chronicity 
limited,  e.g.  rheumatoid  arth- 
ritis, chronic  Bright's  disease, 
etc. 

6.  Reflexes  probably  unaltered. 


Comments  on  the  Table,  and  Additional  Remarks 

I.  The  examination  of  blood  and  urine  are  expressly  mentioned 
to  avoid  the  mistaking  for  primary  nervous  affections  the  numerous 
vague  and  obscure  secondary  phenomena  that  occur  in  anaemia  and 
other  primary  blood  dyscrasiae,  and  are  the  prominent  symptoms 
of  chronic  and  even  acute  uraemia.     A  careful  examination  of  the 

T 


274 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


pelvic  organs  will  often  reveal   a  very  substantial  cause  (neoplasm, 
parametritis,  etc.)  for  a  puzzling  sciatica. 

2,  In  children,  and  even  sometimes  in  adults,  it  is  difficult  to 
distinguish  between  the  refusal  to  move  a  limb  or  part  because 
such  movement  causes  pain  (pseudo-paralysis)  and  the  incapability 
of  such  movement ;  the  effect  of  passive  movement  painful  in  the 
former,  not  in  the  latter,  is  the  simplest  test,  and  usually  sufficient. 
Other  cases  in  which  movement  causes  exaggeration  of  already 
present  pain  will  be  referred  to  in  various  places  where  the  fact  is  of 
use  in  separating  individual  complaints. 

Inco-ordination  of  movements,  and  tremors  on  effort,  are  very 
suggestive  of  primary  nerve  lesions,  the  various  forms  of  Grave's 
disease  being  the  chief  fallacy. 

General  convulsions  and  local  spasmodic  twitchings  of  muscles 
constitute  evidence  of  such  importance  as  to  require  separate  con- 
sideration. 

Vomiting,  if  reflex  from  nerve  lesions,  is  usually  paroxysmal, 
very  persistent  during  a  paroxysm,  and  not  accompanied  by  much 
nausea  as  a  rule ;  it  may  be  excited  by  food,  but  occurs  equally 
independent  of  it  {vide  p.  158). 

Mental  changes,  except  when  accompanied  by  pyrexia,  are 
almost  always  indicative  of  an  essential  nerve  lesion,  most  commonly 
of  the  nutritional  type  when  the  symptom  is  primary ;  when  it  is 
secondary  to  some  organic  destruction  its  cause  is  usually  fairly 
obvious. 

Wasting,  if  general,  rarely  points  to  organic  disease  of  the 
nervous  system ;  but  if  local,  it  becomes  very  suggestive  of  such  a 
causation  {vide  p.  252). 

Acute  and  Sub-Acute  Symptom  Groups 


<U    C    >:1 


V^^ 

S    rt 


o  "3  o  >H  g  kI 

P-i  a  rt  o  rt  o 


If  Caused  by  Essential  Affection  of 
Nervous  System. 

1.  Pathological  activity,  or  pos- 
sibly inactivity  of  nerves 
(headache,  pain,  spasm,  de- 
lirium, etc.),  out  of  propor- 
tion to  the  degree  of  fever, 
and  not  necessarily  abating 
with  defervescence. 

2.  Rapid  onset  of  actual  loss  of 
function  of  nerves — paralysis, 
anaesthesia,  etc. 


a.    \ 


If  Secondarily  or  Reflexly 
Nervous. 

This  activity  or  its  re- 
verse is  more  or 
less  proportional  to 
the  fever  ;  usually 
abates  with  it. 


No  paralysis,  or  if  so, 
it  is  pseudo-paralysis. 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  275 

On  this  tabular  differential  diagnosis  of  acute  symptom  complexes 
it  is  only  necessary  to  remark  that  there  are  but  few  general  points 
that  can  be  utilised  for  the  purpose.  In  the  cases  in  which  the 
greatest  difficulties  and  the  most  serious  mistakes  are  likely  to 
occur  the  differential  points  are  rather  special  than  general, 
and  consequently  the  diagnosis  ^^'ill  be  found  in  special  tables; 
vide — 

Meningitis  v.  Pneumonia,  pp.  95  and  96. 

Tubercular  Meningitis  v.  Gastritis,  pp.  159  and  160. 

Infantile  Paralysis  v.  The  Exanthemata,  p.  292. 

Acute  Mania  v.  Delirium  Tremens. 

Organic  v.  Functional  Lesions 

We  may  now  continue  with  general  differential  diagnosis,  on 
the  assumption  that  the  case  before  us  is  really  and  essentially 
nervous.  The  next  point  to  determine  is  whether  it  be  organic  or 
functional. 

Even  in  an  elementary  work  it  is  impossible  to  avoid  glancing 
at  a  definition  of  these  terms.  The  difficulties  in  the  way  of  an 
accurate  investigation  of  the  microscopical  details  of  the  (whole  of 
the)  nervous  system  have  hitherto  been  so  great  as  to  practically 
prevent  a  final  decision  of  the  question,  "Is  the  picture  of  structure 
normal  or  abnormal,  physiological  or  pathological  ?  "  and  then  of  the 
question,  "  Did  the  ill-regulation  of  function  during  life  depend 
upon  the  peculiarities  of  structure  which  have  been  noted  ?  "  As 
modern  methods  of  microscopical  technique  (hardening,  preserving, 
staining,  etc.)  become  more  and  more  perfect,  we  are  coming  more 
and  more  to  the  conclusion  that  a  final  answer  can  be  given  to  the 
first  of  these  questions,  and  probably,  in  consequence,  to  the  second, 
so  that  the  field  of  genuine  functional  diseases  is  rapidly  becoming 
more  and  more  restricted. 

Theoretically,  we  can  conceive  that  a  piece  of  living  m.achinery 
that  was  originally  (in  congenital  troubles  the  same  argument 
applies  to  the  development  of  structure)  capable  of  carrying  out 
its  due  function  properly  and  in  harmony  with  the  functions  of 
other  nervous  complexes  may  work  improperly  or  inharmoniously 
(  =  disease)  by  assuming  (i)  that  its  structure  has  got  damaged,  or 
(2)  that  its  supply  of  nutriment  is  faulty  (excessive,  inadequate,  or 
deleterious),  or  (3)  that  it  individually  is  suffering  from  wrong  con- 
trol (imperfect,  excessive,  or  perverted)  by  other  "centres."  The 
last  two  would  correspond  to  functional,   the    first  to   structural, 


276  DIFFERENTIAL  DIAGNOSIS  chap. 

disease;  but  it  is  very  easy  to  see  that  what  was  at  first  purely 
functional,  qua  a  given  "centre,"  may  readily  result  in  organic 
destruction  if  the  untoward  influences  persist. 

As  common  examples  of  diseases  which  are  at  present  frequently 
thought  of  as  functional,  and  illustrating  the  above  theory,  I  would 
mention — 

Epilepsy. — Due  primarily  to  a  fine  (some  day,  I  believe,  to  be 
definitely  described)  organic  change  in  structure  of  a  centre  or 
centres,  kept  up  or  made  worse  by  improper  nutriment.  Witness 
the  bad  influence  of  some  diets  (meat)  on  epileptics. 

Hysteria  and  Neurasthenia. — Due  primarily  to  imperfect  nutrition 
of  higher  centres,  and  then  a  consequent  loss  of  control  of  these  over 
lower  centres  which  exhibit  the  symptoms.  (Some  cases  are  very 
close  to  deliberate  malingering.) 

Neuralgias. — Often  due  to  organic  (inflammatory)  changes,  but 
strictly  to  improper  nutrition. 

Delirium  and  other  Pheiiomena  of  Fevers  and  of  Apyrexial  Toxcemia. 
— Due  at  once  and  essentially  to  deleterious  substances  supplied  to 
the  nerve,  often  ending  in  definite  structural  trouble.  (Witness 
diphtheria,  influenza,  etc.) 

Manias  and  Permanent  Menial  Obliquities. — In  causation  closely 
allied  to  the  temporary  troubles  of  fevers,  etc. ;  but  more  frequently 
the  cause  ends  in  fine  microscopical  changes,  which  are  already  being 
investigated  with  success. 

Occupation  Neuroses. — Essentially  due  to  overwork,  which  in  turn 
leads  to,  or  is  associated  with,  imperfect  nutrition  by  excess  of 
waste  products.  (These  cases  are  very  often  ones  of  definite 
neuritis.) 

Minor  Symptoms  of  Diseases  of  Brain. — Are  in  themselves  nothing 
but  functional,  and  are  illustrations  of  perverted  control.  Typical 
examples  are  alteration  of  reflexes,  disturbances  of  visceral  functions, 
etc. 

Considering  the  very  small  capability  of  repair  possessed  by  the 
nervous  system  when  once  a  cell  has  been  damaged,  it  would  seem 
almost  suflScient  to  define  organic  as  that  which  is  incapable, 
functional  as  that  which  is  capable,  of  repair.  Excepting  inflamma- 
tory troubles,  this  is  very  nearly  my  meaning  in  what  follows. 

Most  commonly  the  point  will  be  obvious  from  the  general 
aspect  and  history  of  the  patient,  but  in  cases  of  doubt  the  follow- 
ing table  will  assist  us : — 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM  277 


Organic. 

Onset. 

If  sudden,  usually  the  symptoms 
are  fairly  definite  and  local- 
ising. 

If  chronic,  it  is  still  usually  fairly 
constant  in  character,  and  con- 
sistent in  progress. 

Motor  Symptoms. 

Pa?'alysis. — Far   and    away  the 
most  common  result ;  if  flaccid 
it  is  rapidly  followed  by  R.D.  ; 
in  all  cases  its  distribution  is 
in    accordance    with    known 
anatomical  structure,  and  ob- 
jective  signs   may  frequently 
be  found  when  due  to  lower 
level  lesions  ;  constant  in  posi- 
tion when  once   apparent,  at 
least   does    not    dodge   from 
limb  to  limb  ;  may  be  incom- 
plete. 
Spasm. — Rarely  due  to  organic 
lesion    except    in    Jacksonian 
epilepsy  and  the  convulsions 
of     meningitis;     may    occur 
during    sleep;    when   organic 
usually  a  definite  known  causa- 
tion in  history. 

Sensory  Symptoms. 

Not  common  as  the  sole  com- 
plaint ;  if  it  is  the  only  com- 
plaint it  is  usually  definite  and 
localising. 


Reflexes. 

Experimental.  —  Most  usually 
definitely  and  permanently 
altered,  and  in  a  constant 
direction  for  the  individual 
case. 


Functional. 

If  sudden,  it  is  less  definitely  local- 
ising, and  symptoms  more  vague, 
frequently  prominently  mental. 

If  chronic,  it  is  very  inconstant  in 
features,  and  inconsistent  in  pro- 
gress. 

Also  tolerably  common,  but  even  if 
flaccid,  R.D.  never  develops  ;  in 
most  cases  it  is  apparently  due 
to  lower  level  lesion,  and  yet  no 
objective  signs  to  be  found  ;  its 
distribution  varies  from  time  to 
time ;  usually  complete  in  the 
member  complained  of. 


Verycommon;  usually  ceases  during 
sleep  ;  no  ascertainable  cause  in 
the  history. 


Often  enough  the  sole  complaint, 
indefinite  and  non  -  localising  ; 
definite  hemianaesthesia  will  be 
unassociated  with  any  features 
pointing  to  organic  brain  trouble, 
e.g.  hemiplegia  or  unconscious- 
ness at  onset. 

Variable  in  diflferent  cases  which 
are  otherwise  similar,  and  also 
in  the  same  case  from  day  to 
day. 


278 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Organic. 

Visceral. — Micturition  and  defas- 
cation  often  seriously  affected, 
as  also  many  other  visceral 
functions. 

Vascular. — Often  loss  of  vaso- 
motor control,  limbs  cold,  and 
circulation  too  easily  influ- 
enced by  local  conditions ; 
may  cause  serious  anxiety. 

Mental  Changes. 

When  present  usually  persistent, 
and  are  associated  with  other 
definite  indications  of  organic 
trouble. 

Total  Aspect  and  Course. 

Constant. 

Consistent. 

Definite. 


Functional. 

Rarely  or  never  serious  visceral 
mischief,  but  there  may  be 
troublesome  retention  of  urine. 

Such  loss  of  control  only  shows 
itself  in  turgescent  directions 
(factitious  urticaria,  e.g.)^  or  very 
temporary  coldness  and  white- 
ness :  never  looks  serious. 


Characteristically  variable,  and 
present  before  illness,  or  at  least 
not  directly  caused  by  it ;  unas- 
sociated  with  other  definitive  in- 
dications. 


Inconstant. 

Inconsistent. 

Indefinite. 


The  mimicry  of  organic  disease  by  functional  changes  is,  how- 
ever, sometimes  so  complete  and  so  intricate  that  further  details 
can  only  be  given  in  special  cases. 

Assuming  that  we  have  determined  the  case  to  be  one  of  organic 
disease,  one  of  the  first  questions  that  requires  an  answer  will  be — 
"Is  it  of  the  brain  or  encephalic  structures,  or  is  it  of  the  cord  (in- 
cluding medulla)  or  periphery  ?  " 

The  clearest  method  of  reply  is  to  divide  all  cases  into  two 
categories:  (i)  acute,  a  week  or  less;  (2)  chronic,  a  month  or 
over. 


A. — Acute  Nervous  Lesions 

Before  deciding  as  to  an  apparently  acute  case  it  is  exceedingly 
important  to  make  inquiries  into  the  previous  history  of  the  patient, 
because  the  following  acute  incidents  in  chronic  diseases  may  mis- 
lead us : — 

Fits  in  epilepsy. 

„      general  paralysis  of  the  insane. 
„      chronic  poisoning  (alcohol,  lead,  etc.). 
cerebral  tumours. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


279 


Crises  in  tabes  dorsalis. 

Acute  features  in  chronic  spinal  caries. 

„  „  ear  disease,  etc. 

,,  ,,  meningitis. 

Excluding  such  cases,  the  following  points  are  most  important : — 


Onset. 

Consciousness. 

Motor  Symptoms. 
Cranial  Ne?  ves. 


Paralysis  or  paresis 
or  excessive  move- 
ment. 


Sensory  Symptoms. 


Reflexes. 


Intracranial. 

Very  sudden  onset  is 
extremely  common. 

Very  often  interfered 
with  in  some  degree. 


Often     implicated 
some  degree. 


m 


Almost  invariably  on 
one  side ;  if  on  both, 
nearly  sure  to  be 
much  interference 
with  consciousness 
or  with  cranial 
nerves,  as  in  ven- 
tri  cular  h  asmorrhage 
or  pontine  lesions. 

Comparatively  rare 
alone  ;  if  present, 
they  are  of  the  hemi- 
type. 


Of  eye  frequently  lost. 


Knee  jerk    frequently 
altered  on  one   side 


Cord  and  some  Peri- 
pheral Lesions. 

Such  suddenness  is 
rare. 

Practically  never  inter- 
fered with. 

Rarely  or  never  impli- 
cated, unless  it  be 
as  regards  the  dila- 
tion of  pupil,  and 
in  post  -  diphtheritic 
paralysis. 

Almost  invariably  on 
both  sides,  owing  to 
nearness  of  the  two 
sides  in  the  cord, 
and  to  the  sym- 
metry of  peripheral 
nerves  in  liability  to 
poisoning  ;  area  of 
disturbance  very 
small  if  one-sided. 

Very  common  indeed, 
and  of  the  para- 
type;  because 
motor  and  sensory 
tracts  are  so  close 
together  in  cord,  and 
both  have  a  nearly 
equal  tendency  to 
suffer  in  poisoning 
(?  except  diphtheria). 

Of  eye  lost  sometimes 
in  lesions  high  up 
in  cord. 

Frequently  altered,  but 
more    probably    on 


28o 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Intracranial. 

only,  unless  great 
excess  of  intracra- 
nial pressure. 

Bladder  and  rectum 
rarely  affected,  un- 
less consciousness 
is  much  interfered 
with. 


Cord  and  some  Peri- 
pheral Lesions. 

both  sides,  and  that 
without  evidence  of 
intracranial  pres- 
sure. 
Bladder  and  rectum 
often  interfered  with 
in  acute  cord  lesions, 
and  that  without 
interference  with 
mental  clearness. 


If  the  case  be  a  less  acute  one  (over  a  month),  and  seems  to  be 
stationary  or  progressing,  the  following  table  may  be  constructed : — 


B. — Chronic  Nerve  Lesions 


Intracranial.  v. 

History. 

More  frequently  a  history  of 
an  acute  attack  or  attacks, 
and  if  such  be  the  case, 
symptoms  very  possibly 
stationary  or  improving ; 
tumours  the  great  excep- 
tion. 
Motor  Symptoms. 

Jacksonian      epilepsy     {q.v.) 
common  enough. 

One  side  most  likely  alone 

affected. 
Cranial    motor   nerves    often 

affected. 


Sensory  Symptoms. 

Again  one-sided  and  cranial  ; 
"pins  and  needles,"  and 
other  parsesthesias,  if  pre- 
sent, are  of  one  arm  or  leg, 
or  one  side. 


Extracranial. 

Less  frequently  such  history  with 
stationary  symptoms ;  the  symp- 
toms are  likely  to  be  progressing, 
except  in  cases  of  definite  myelitis. 


Such  uncontrollable  movements  only 
take  the  shape  of  twitching  in  legs 
or  arms. 

Both  sides  most  often  affected. 

Cranial  nerves  rarely  affected  except 
in  disseminated  sclerosis  and  in 
tabes  dorsalis,  in  both  of  which  the 
lesion  may  extend  to  encephalic 
centres. 

Both  sides,  and  not  cranial ;  "  pins 
and  needles,"  if  symmetrical,  almost 
pathognomonic  of  a  peripheral 
lesion  ;  sensory  disturbances  in  cord 
troubles  nearly  sure  to  be  acutely 
painful  or  completely  anaesthetic. 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  281 

Intracranial.  v.  Extracranial. 

Reflexes. 

Often    one-sided    change ;    if     Equally    affected,    and    that    without 
both    sides,    nearly  certain  mental  symptoms, 

to     have     cranial     nerves 
affected,   or  mental  symp- 
toms. 
Mental  Changes 

Common.  Never    present    in    a    purely    cordal 

lesion,    or     in     one     of    peripheral 
nerves. 

It  is  impossible  to  pursue  the  plan  of  general  tables  for  differ- 
ential diagnosis  farther,  owing  to  the  mass  of  details  necessary  for 
complete  diagnosis,  which  w^ould  be  quite  irrelevant  in  many  in- 
dividual diseases.  We  must  now  proceed  to  consider  the  separate 
affections,  with  tables  to  differentiate  those  which  are  more  nearly 
similar. 

Peripheral  Neuritis 

The  existence  of  lesions  of  the  peripheral  nerves,  independent 
of  trouble  in  the  cord  and  brain,  has  only  been  determined  within 
quite  a  recent  period ;  consequently,  the  first  and  commonest  diffi- 
culty in  their  diagnosis  arises  from  a  want  of  famiHarity,  not  with 
cases  of  the  disease  itself,  for  they  are  only  too  frequent,  but  with 
the  idea  of  its  existence ;  and  non-acquaintance  has,  as  its  natural 
corollary,  non-recognition.      It  may  be  laid  down  as  a  law  that — 

"  In  the  gross  total  of  nervous  diseases  peripheral  neuritis,  in 
some  one  of  its  many  forms,  is  exceedingly  common,  and  its  possible 
presence  must  always  be  borne  in  mind." 

Now,  how — in  what  connections — does  it  occur,  and  what  are 
its  prominent  features  ?  As  far  as  diagnosis  is  concerned,  it  occurs 
in  two  fairly  distinct  forms  : — 

{a)  More  or  less  localised  to  individual-named  nerves  and  their 
branches ;  a  search  along  which  will  often  reveal  the  cause  of  the 
trouble,  e.g.  a  septic  wound  or  tumour  causing  pressure,  though  it 
must  not  be  forgotten  that  general  constitutional  poisons,  such  as 
rheumatism,  gout,  or  lead,  may,  and  often  do,  produce  such  local 
asymmetrical  affections. 

{b)  More  universal  affection  of  a  large  number  of  nerves 
(multiple  neuritis  of  authors),  almost  invariably  due  to  a  poison 
carried  by  the  blood,  e.g.  alcohol,  etc.,  and  almost  invariably  sym- 
metrical. 


282  DIFFERENTIAL  DIAGNOSIS  chap. 

It  is  rather  a  peculiarity  of  peripheral  nerve  troubles  that  they 
are  often  either  of  sensory  or  of  motor  nerves  only,  a  point  apt  to 
be  overlooked ;  but  mixed  cases,  both  sensory  and  motor,  are  per- 
haps more  commonly  met  with.  The  prominent  symptoms  are  the 
following : — 

1.  Motor  Side. — Weakness  and  wasting  of  muscles,  -^ith.Jlacdd 
paralysis,  and  possibly  R.D. ;  certainly  R.D.  if  the  case  is  severe, 
because  the  peripheral  neuron  is  the  main  channel  by  which  nutri- 
tion of  terminal  organs  is  maintained. 

2.  Sensopy  Side. — The  inflammation  acts  as  an  irritant  of  the 
peripheral  sensory  neuron,  possibly  proceeding  even  to  complete 
destruction  of  function  ;  hence  we  get — 

(a)  "  Pins  and  needles  "  and  numbness.  If  these  are  well  marked 
and  persistent,  and  on  both  sides,  they  are  almost,  if  not 
quite,  pathognomonic  of  a  peripheral  lesion. 

(p)  Pain  and  hyperaesthesia  in  the  known  area  of  distribution 
of  certain  sensory  nerves. 

{c)  Anaesthetic  patches.  These  require  to  be  looked  for,  as 
the  patient  has  very  probably  not  appreciated  their  pre- 
sence. Possibly  these  anaesthetic  regions  or  areas  may 
be  the  alleged  seat  of  painful  sensations — paradoxical  or 
painful  anaesthesia. 

3.  Reflex  Side.  —  Experimental  reflexes,  especially  the  knee 
jerk,  either  grossly  exaggerated  (in  early  stages),  or  more  probably 
absent ;  visceral  reflexes  are  almost  universally  unaffected,  so  that 
serious  disturbance  of  micturition  or  defaecation  is  practically  con- 
clusive proof  that  the  cord  or  brain  is  affected. 

4.  Trophic  Side. — Muscles  waste  rapidly  {vide  Motor  Side) ;  the 
skin  and  its  appendages  show  very  characteristic  appearances  ;  nails 
become  brittle  and  crack  very  readily ;  hair  falls  out  or  is  tempor- 
arily excessive  in  growth  ]  skin  becomes  very  smooth,  shiny,  and 
thin. 

5.  Cranial  nerves  may  be  affected,  but  if  so,  entirely  without 
general  symptoms,  and  also  without  any  pathological  mental  pheno- 
mena. 

If,  then,  in  a  given  patient  some  or  many  of  the  above  are 
present,  we  must  suspect  a  peripheral  lesion,  and  inquiry  or  volun- 
teered statements  may  then  very  likely  reveal  the  presence  of  some 
antecedent  condition  known  either  to  predispose  or  to  excite  such 
changes.  These,  with  the  leading  feature  of  the  resultant  neuritis, 
are  given  in  the  following  table  in  rough  order  of  frequency. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


283 


Clinical  Causes  of  Peripheral  Neuritis 


Injury,  including  local  in- 
flammation and  pressure  ; 
septic  wounds  ;  necrosis  of 
bone,  syphilitic,  tubercular, 
cancerous,  aneur^j-smal,  etc., 
tumours ;  probably  as  a 
sub-group  come  occupation 
neuroses  (often  neuritis). 

Diphtheria. 


Causation  obtrusive  ;  only  the  pain  or 
paralysis,  or  both,  make  one  say 
neuritis  is  present  ;  the  case  is 
named  from  the  causation,  and  not 
necessarily  called  neuritis. 


3.  Rheumatism  and  gout. 


4.  Alcohol  (with    this,    but   in- 

finitely rarer,  must  be  put 
poisoning  by  CSg,  aniline, 
and  a  few  other  trade 
products). 

5.  Lead. 


2.   Diphtheria.  Symptoms  almost  entirely  motor,  and 

especially  of  the  eye  and  palate, 
but  knee  jerks  almost  invariably 
absent. 

Almost  entirely  sensory,  and  pain  in 
the  course  of  a  nerve,  with  a  history 
of  gout  or  rheumatism,  the  chief 
guides. 

Both  sensory  and  motor ;  here  "  pins 
and  needles "  is  a  very  constant 
feature,  with  progressive  weakness 
in  legs  and  arms  ;  history  of  alcohol 
(possibly  denied)  or  of  trade  occu- 
pation. 

As  a  peripheral  nerve  trouble,  usually 
confined  to  wrist  drop,  and  colic 
(?  nervous) ;  blue  line  on  gums  is 
the  guiding  feature. 

6.  Arsenic.  Sensory  and  motor,  usually  preceded 

or  accompanied  by  coryzal  symp- 
toms. 

7.  Diabetes.  Glycosuria ;    mainly  neuralgic    symp- 

toms in  a  given  nerve  ;  also  absence 
of  knee  jerks. 

8.  Cases  occurring  in  the  course  of  the  exanthemata,  which  present  no 

special  diagnostic  points  ;  also  in  anaemia  and  other  cachectic 
conditions,  e.g.  senility. 

9.  Malaria,    leprosy,    beri-beri,  and   other   tropical   forms   too   rare    in 

England  to  require  further  notice  here. 

The  presence  of  one  or  more  of  these  causes  will  then  often  go 
far  towards  clinchmg  the  diagnosis.  Cases  will,  however,  often 
enough  occur  in  which  the  cause  is  not  obvious  —  overlooked, 
denied,  or  forgotten — and  we  may  have  to  depend  on  the  symptoms 
alone  for  a  diagnosis. 


284 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


For  what  affections  can  the  symptoms  of  peripheral  neuritis  be 
mistaken  ?  Simple  neuralgia  and  affections  of  the  cord  and  brain 
are  the  ones  chiefly  requiring  distinction. 

Neuritis  v.  Neuralgia 

I  have  adopted  the  word  "  neuralgia  "  here  to  indicate  a  pain  not 
due  to  gross  organic  changes  in  a  nerve,  for  the  diagnostic  problem 
I  wish  to  try  to  solve  is  the  following :  Is  this  pain  complained  of 
by  the  patient  a  purely  reflex  phenomenon,  or  at  least  only  due  to 
nutritional  (so-called  functional)  changes,  or  is  it  due  to  gross  organic 
changes,  of  which  actual  neuritis  is  our  present  example?  The 
following  table  gives  the  main  points  of  difference : — 


Table 


Reflex  or  Functional,  i.e.  Neuralgia. 

More  likely  to  be  paroxysmal  in 
character. 

Spontaneous  in  onset,  independent 
of  use  of  nerve,  and,  in  fact, 
often  better  during  bodily  activ- 
ity. 

Intermittency  complete,  and  history 
may  show  long  intervals  of  in- 
termittency. 

Situation  often  variable  from  day 
to  day,  but  almost  invariably 
unilateral  in  any  given  attack. 

If  points  douleureux  present,  which 
they  rarely  are,  pressure  on  them 
causes  pain  at  the  periphery. 

Little  or  no  local  tenderness  along 
nerve  trunk,  and  especially  a 
light  pressure  will  cause  as  much 
pain  as  a  heavier  one. 

Wasting  or  other  trophic  dis- 
turbances never  present  at  first, 
and  only  rarely  after  a  long 
time. 


Organic,  i.e.  Neuritis. 
Less  likely  to  be  of  this  character. 

Pain  usually  excited  by  movement, 
often  subsides  when  a  posture 
of  rest  adopted,  and  always 
worse  after  use. 

If  intermittent,  rarely  completely 
so,  and  not  for  long. 

Situation  never  variable  from  day 
to  day ;  more  commonly  bilateral, 
but  may  be  either. 

Points  douleureux  usually  present, 
and  pressure  on  them  causes 
very  distinct  local  pain,  as  well 
as  perhaps  peripheral. 

Generally  local  tenderness  along 
nerve  trunk,  and  pain  much 
more  proportional  to  amount  of 
pressure. 

Wasting  and  trophic  disturbances 
nearly  certain  to  appear  rapidly, 
and  may  even  proceed  to  R.D. 
in  muscles. 


Some  of  these  points  can  be  investigated  with  a  definite  result 
in  any  stage  of  the  malady,  but  for  others  time  must  be  allowed, 
and  often  in  the  early  days  of  symptoms  a  definite  diagnosis  is 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  285 

impossible ;  but  if  the  cause  be  organic  the  nerve  is  almost  sure  in 
a  very  short  time  to  show  very  definite  signs  of  loss  of  function  and 
degeneration,  whereas  a  reflex  or  functional  pain  may  continue  for 
years  without  such  signs. 

To  avoid  needless  repetition,  the  further  distinction  between  peri- 
pheral neuritis  and  cord  troubles  can  be  better  discussed  after  we 
have  considered  an  outline  of  the  functions  and  affections  of  the  cord. 


DISEASES  OF  THE  SPINAL  CORD 

Of  the  real  exciting  causes  of  primary  affections  of  the  spinal 
cord  we  know  very  little,  indeed  practically  nothing.  This  is  in 
great  contrast  to  our  knowledge  of  causes  of  peripheral  troubles, 
but  traumatism  (external  and  internal),  tumours,  acute  inflamma- 
tion, and  a  slowly  destructive  process — ultimately  ending  in  de- 
generation of  neurons  and  a  condition  known  as  sclerosis — are  the 
chief  clinical  causes  of  those  pathological  symptoms  which  we 
discover  by  examination.  It  must  be  accepted  as  a  fact  that  the 
last-mentioned  cause  (and  often  also  acute  inflammation)  has,  to  an 
extraordinary  degree,  a  habit  or  power  of  attacking  parts  of  the 
spinal  cord  possessing  analogous  function,  and  symmetrically  situated 
on  either  side  of  the  middle  line.  So  constantly  is  this  the  case 
that  these  affections  are  now  spoken  of  as  system  diseases  in 
opposition  to  the  indiscriminate  lesions  produced  by  tumours, 
haemorrhages,  etc. 

System  Lesions  of  Spinal  Cord 

The  systems  thus  picked  out  are : — 

1.  The  cells  of  the  anterior  cornua ; 

2.  The  fibres  of  the  pyramidal  tracts  (crossed  and  direct)  ; 

3.  The  fibres  of  the  posterior  columns ; 

and  the  names  given  to  the  diseases  thus  produced  may  usefully 
be  tabulated  as  follows  : — 

Anterior  Cornua — 

p  .  j  Chronic     =  Progressive  muscular  atrophy. 

^  I  Acute        =  Infantile  (or  adult)  spinal  paralysis. 
Secondary  to  acute    =  Myelitis  or  tumour  pressure,  etc. 
Lateral      Columns 
OR      Pyramidal 
Tracts — 

Primary  =  Primary  lateral   sclerosis   or   spastic   para- 

plegia. 


286 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Secondary  1  =  Secondary    spastic    paraplegia,    caused    by 

any  destruction  of  the  nutritive  cells  in 
the  rolandic  cortex,  or  by  division  or 
destruction  of  the  main  neuron  stems 
from  them,  such  as  is  left  by  an  acute 
transverse  myelitis. 

Posterior  Columns — 

Primary  =  Tabes  dorsalis  or  locomotor  ataxy. 

Secondary  =  Acute  myelitis  or  tumour  pressure,  etc. 

Besides  these  pure  or  simple  lesions  we  have  two  named  com- 
binations— • 

Combination  of  anterior  cornua  and  =  Amyotrophic  lateral  sclerosis. 

pyramidal  tracts. 
Combination    of  pyramidal    tracts  =  Ataxic  paraplegia. 

and  posterior  columns. 

The  diseases  in  the  right-hand  column  form  then  the  labels  of 
the  system  lesions  of  the  cord.  With  the  exception  of  acute  anterior 
poliomyelitis  they  are  all,  when  primary,  i.e.  without  obvious  cause, 
chronic  in  onset  (a  year  or  more).  After  or  during  an  indiscrimi- 
nate lesion  (tumour,  haemorrhage  or  softening,  traumatism,  acute 
myelitis,  all  of  which  except  tumour  are  acute  or  sub-acute  in  onset) 
the  symptoms  of  the  system  lesion  constitute  the  evidence  of  loca- 
tion vertically  and  horizontally.  We  will  now  proceed  then  to  tabu- 
late the  known  functions  of  the  systems  to  get  a  firm  foundation  for 
differential  diagnosis : — 


Motor 


Table 

Functions  of  Systems  of  Cord 
Pyramidal  Tracts.         Anterior  Cornua. 


Telegraph  wires 
conveying 
motor  mes- 
sages from  cells 
of  rolandic  cor- 
tex to  dendrites 
of  cells  of  an- 
terior cornua. 


Receive  by  their 
dendrites 
motor  mes- 
sages from 
pyramidal 
tracts. 


Posterior  Columns. 

Nil. 


1  This  is  not  usually  named  as  a  separate  disease,  but  a  symptom-complex  or 
residual  condition  produced  by  or  left  after  the  lesions  mentioned — tumour,  haemor- 
rhage, inflammation,  etc. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


287 


Sensory. 


Pyramidal  Tracts. 
Nil. 


Anterior  Cornua. 
Nil. 


Reflex. 


Trophic. 


Transmit  im- 
pulses from  the 
brain  having  a 
restraining  in- 
fluence  on 
spinal  reflexes. 

Nil. 


Form  a  link  in  the 
reflex  chain  for 
any  given  level. 


Forms  the  main 
source  of  tro- 
phic influences 
for  the  peri- 
pheral neuron 
and  for  the 
muscles. 


Posterior  Columns. 

Sensory  telegraph 
wires  convey- 
ing messages 
from  skin, 
muscles,  etc., 
up  to  medulla 
and  brain. 

Also  form  a  link 
in  the  chain  at 
a  given  level. 


Possibly  transmit 
trophic  influ- 
ences to  skin. 


The  Consequent  Symptoms  of  Irritation  or  Destruction  of  the  Systems  a7'e 


Pyramidal  Tracts.         Anterior  Cornua.         Posterior  Columns. 


Motor. 
*  At     the 
seat     of 
lesion. 


*  Below  the 
seat  of 
lesion. 


Movements  or 
paralysis  cor- 
responding to 
the  fibres  going 
out  at  the  level. 

Movements  or 
paralysis  pro- 
portional in 
extent  to  the 
number  of 
fibres  d  e- 
stroyed,  hence 
may  be  merely 
general  weak- 
ness ;  paralysis 
not  flaccid. 


Paralysis  flaccid, 
and  with  R.D. 
in  muscles. 


No  influence  on 
lower  cells  and 
muscles. 


Inco  -  ordination 
without  loss  of 
power ;  due  to 
interruption  of 
afferent  im- 
pulses from 
muscle  by  the 
sensory  nerves 
to  the  encepha- 
lon  or  head  co- 
ordinat ing 
centre;  no  para- 
lysis or  convul- 
s  i  V  e  m  o  v  e- 
ments. 


*  The  reason  for  the  difference  in  symptoms  at  the  seat  of  lesion,  and  above  and 
below  it,  should  be  most  carefully  noted.  It  is  that  the  posterior  columns  and  the 
pyramidal  tracts  are  merely  bundles  of  telegraph  wires,  the  vast  majority  of  which 


288 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Pyramidal  Tracts. 

Sensory. 
■^  A  t    the     Nil. 
seat. 

*  Below  the     Nil. 


Anterior  Cornua. 
Nil 

Nil. 


Reflexes  A  of  Experimental  Production. 


*  At    the 
seat. 

*  Below  the 

seat. 


Absent  from  break 
in  chain. 


Posterior  Columns. 

Root  pains  pos- 
sibly, girdle 
sensation. 

Anaesthesia  of 
opposite  side 
proportional  to 
the  number  of 
fibres  d  e- 
stro.yed  ;  pains 
possible  from 
irritation  of  un- 
destroyed 
fibres. 


Absent  from  break 
in  chain. 


Absent  knee  jerk 
in  destructive 
lesions  from 
break  in  chain. 

Increased  from 
absence  of  re- 
straint in  de- 
structive 
lesions  ;  in  irri- 
tative lesions 
knee  jerk  is 
variable. 


are  in  any  given  section  of  the  cord  merely  passing  through  the  seat  of  section,  con- 
ducting impulses  which  actually  exhibit  themselves  lower  down  or  higher  up  as  motion 
or  perception  ;  it  is  only  a  very  few  that  at  any  point  leave  the  cord  as  the  direct  con- 
tinuation of  a  peripheral  neuron  with  incoming  or  outgoing  message.  The  reverse  is 
the  case  with  the  cells  of  the  anterior  cornua,  which  are  all  of  them  in  any  section 
individually  in  relationship  with  peripheral  neurons  proceeding  from  that  plane  of 
section  (or  at  least  from  very  closely  situated  planes)  ;  they  have  no  serial  functional 
relationships  (of  clinical  utility  at  present  at  any  rate)  with  more  distant  cells  above 
and  below.  A  similar,  I  might  almost  say  the  same,  explanation  may  be  given  of 
the  term  "root  symptoms,"  an  expression  frequently  used  in  nervous  clinical  patho- 
logy. It  means  symptoms,  motor  or  sensory,  which  can  be  traced  to  irritation 
(usually),  or  destruction  of  the  peripheral  neurons  constituting  a  motor  or  sensory  root 
of  a  spinal  nerve,  either  just  outside  the  cord  or  just  within  it  (after  they  have  left  the 
cells  of  the  anterior  cornua  in  motor  cases,  before  they  have  been  separated  in  the 
posterior  columns  in  sensory  cases),  but  leaving  the  cord  at  that  plane;  they  will 
obviously  be  segmental  in  distribution,  i.e.  a  girdle  pain  or  a  local  pain  in  the  back 
corresponding  to  the  sensory  nerve,  or,  on  the  other  hand,  a  twitching  or  paralysis 
and  atrophy  of  certain  muscles  corresponding  to  named  motor  nerves. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


289 


B  of  Viscera, 


Pyramidal  Tracts.         Anterior  Cornua.         Posterior  Columns. 


No  voluntary  as- 
sistance to  the 
act  possible, 
but  the  centres 
may  work  har- 
moniously. 


Trophic  to  Skin  and  Muscles. 

*  At     the     No  effect, because 
seat.  peripheral  neu- 

ron unaffected. 


■^  Below. 


Nq  effect. 


Loss  of  expulsive 
or  containing 
power  if  in 
lumbar  region, 
and  so  drib- 
bling or  reten- 
tion of  urine  ; 
in  regions  other 
than  the  lum- 
barresult  on  vis- 
cera unknown. 

Rapid  wasting, 
with  R.D.  of 
muscle  fibres 
or  whole 
muscles,  cor- 
responding to 
destroyed  cells. 

No  effect. 


No  consciousness 
of  acts,  and 
great  mischief 
may  ensue  if 
centres  do  not 
work  harmoni- 
ously. 


Bed  sores  not  in- 
frequent, either 
from  anaes- 
thesia or 
absence  of 
usual  trophic 
influences. 

Same  as  at  the 
seat. 


In  addition  to  these  three  systems  we  have  clinical  evidence 
that  the  antero-lateral  ascending  tract  of  Gowers  conveys  impres- 
sions of  pain  and  touch  to  the  sensorium,  and  that  the  gray  matter 
has,  amongst  other  functions,  the  power  of  conveying  impressions  of 
changes  of  temperature  to  the  brain,  and  probably  also  of  control- 
ling the  nutrition  of  the  skin  and  sub-cutaneous  structures.  Sir  W. 
Gowers  has  brought  forward  much  evidence  in  favour  of  the  first  pro- 
position ;  the  known  thermal  ansesthesia  of  syringomyelia  is  sugges 
tive  of  the  correctness  of  the  second ;  and  the  third  is  one  possible 
explanation  of  the  rapid  development  of  bed  sores  in  acute  myelitis. 

These  tables  show  very  distinctly  that  if  a  system  disease  be 
present  in  a  typical  form  confusion  is  impossible,  for  their  symptoms 
present  positive  contrasts  rather  than  comparisons.  The  combined 
chronic  lesions  are  rather  more  confusing,  and  it  is  moreover  true 
that  atypical  and  indiscriminate  lesions  are  frequent,  and  hence  the 
differential  diagnosis  requires  some  little  discussion. 

The  first  caution  and  golden  rule  is,  "  Don't  be  in  a  hurry  to  make 
a  final  and  definite  diagnosis,  to  find,  as  it  were,  a  ready-made  label 

*  See  footnote,  pp.  287-288. 
U 


2  90  DIFFERENTIAL  DIAGNOSIS  chap. 

for  a  case."  Consider  well  the  abse?tce  as  well  as  the  presence  of  posi- 
tive symptoms,  and  then  let  the  diagnosis  run,  "  From  what  I  have 
observed,  I  have  reason  to  believe  that  such  and  such  parts  of  the 
cord  are  affected,  and,  owing  to  the  absence  of  certain  features, 
other  parts  are  exempt."  If  the  case  be  typical  the  appropriate 
label  will  then  be  found,  and  if  atypical  no  opinion  will  have  been 
expressed  which  may  afterwards  have  to  be  withdrawn. 

Indiscriminate  Lesions 

Inasmuch  as  an  indiscriminate  lesion  of  the  cord  can  only  be 
diagnosed,  so  far  as  its  symptoms  are  concerned,  by  its  effects  upon 
those  systems  or  parts  of  the  cord  with  the  functions  of  which  we 
are  more  or  less  acquainted,  i.e.  by  the  same  phenomena — motor, 
sensory,  reflex,  and  trophic — already  several  times  noted,  there 
follow  as  immediate  and  necessary  deductions  (i)  that  the  history 
of  onset  of  the  illness,  and  the  grouping  of  the  signs,  will  be  of  much 
more  importance  than  their  individual  presence ;  (2)  that  the 
vertical  or  horizontal  localisation  will  also  assume  an  equal  impor- 
tance to  ascertain  if  local  therapeutical  measures  offer  a  prospq^t  of 
radical  cure,  e.g.  tumours. 

The  lesions  themselves  are  practically  only  three,  viz.  trauma- 
tism, vascular  lesions  (blocking,  rupture,  or  inflammatory),  and 
tumours,  though  syringomyelia  and  disseminated  sclerosis  ought 
also  to  be  enumerated  if  they  had  not  such  special  characteristics 
of  their  own. 

They  all  of  them  cause  either  irritation  followed  by  destruction, 
or  immediate  destruction  of  the  cord,  and  may  be  classified  from 
that  point  of  view  as  follows  : — 

A.  Irritative   period     Meningitis,  simple  chronic. 

long,  weeks  or     Tertiary      gummata      and      other     tumours     of 

months,  or  even         meninges. 

years.  Aneurysmal  erosion  of  bone  and  compression. 

Spinal  caries  when   products   cheesy  and  possess 
but  feeble  potency  of  irritation,  or  when  gradual 
bone  displacement  causes  pressure. 
Tumour  of  the  bones. 

Traumatism  that  has  only  excited  slight  inflam- 
matory changes. 

B,  Irritative   period     Spinal  caries  with  suppuration  or  sudden  displace- 

short  :  hours  or  ment  of  bone. 

days.  Syphilis  within  two  years  of  infection. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


291 


Tumours  of  any  origin  (occasionally). 
Meningitis,  acute  general. 
Meningeal  haemorrhage. 
C.    Irritative    period     Acute  myelitis  (this  often  occurs  in   cases  where 
almost    non-ex-  longer  irritative   period    might    be  looked  for, 

istent.  e.g.  acute  meningeal  inflammatory  affections). 

Haemorrhage  into  cord,  or  softening  from  blocking 

of  a  vessel. 
Traumatism  when  severe. 

Hence  it  is  obvious  that  it  is  hardly  possible  to  mistake  any  of 
the  members  of  Groups  B  and  C  for  a  system  lesion  (except 
perhaps  acute  infantile  paralysis),  the  history  of  the  onset  of  the 
symptoms  stands  in  such  absolute  contrast.  The  cases  of  Group  A, 
too,  are  almost  invariably  characterised  by  one  distressing  symptom, 
which  is  as  invariably  absent  from  system  lesions,  viz.  severe  local 
pain  or  tenderness  in  the  back,  a  root  symptom  (^.z'.,  p.  288,  foot- 
note). 

Besides  these  two  fundamental  differences  I  only  propose  to  give 
the  following  brief  notes  on  the  diagnosis  of  indiscriminate  lesions. 


Traumatism. 


HAEMORRHAGE 
INTO  OR  SOFTEN- 
ING OF  CORD. 


HAEMORRHAGE 
INTO  MENINGES. 


Tumour  of  menin- 
ges. 


A  definite  history  of  some  violence  always  to  be 
obtained  ;  in  slight  cases  interference  with  mic- 
turition is  the  most  suspicious  circumstance, 
suggesting  serious  cord  trouble ;  a  chronic 
meningitis  or  myehtis  may  arise  from  this 
cause  analogous  to  concussion  of  brain. 

Exceedingly  rare,  onset  instantaneous,  consequent 
and  subsequent  symptoms  those  of  an  acute 
myelitis,  unless  the  clot  or  area  of  softening  be 
very  small,  when  they  will  be  those  of  a  system 
lesion,  only  of  acute  origin,  and  probably 
asymmetrical. 

Also  excessively  rare  except  from  traumatism,  or 
ruptured  aneurysm,  in  each  of  which  diagnosis 
is  obvious  ;  if  a  small  meningeal  haemorrhage 
were  met  with  it  would  be  indistinguishable 
from  localised  meningitis  or  tumour  except  by 
very  sudden  onset. 

Focal  or  root  symptoms  very  prominent ;  com- 
plete symptoms  more  rapid  in  onset  than 
sclerosis,  less  so  than  inflammation  ;  jumpings 
of  a  limb  with  pain  in  it  for  some  months  prin- 
cipal characteristics  from  pressure  on  posterior 
or  lateral  tracts. 


Tumour 

OF 

SUB- 

STANCE 

OF 

THE 

CORD. 

292  DIFFERENTIAL  DIAGNOSIS  chap. 

Very  rare ;  symptoms  similar  to  meningeal  tumour, 
but  much  more  rapidly  progress  towards  a 
paralytic  as  opposed  to  an  irritative  aspect. 

System  Lesions  v.  Peripheral  Neuritis 

We  may  now  return  to  peripheral  neuritis  and  those  affections 
of  the  cord  for  which  it  may  be  mistaken.  There  are  two  systems 
of  the  cord,  disease  of  which  can  obviously  cause  mistakes,  viz.  the 
anterior  cotnua  (motor)  and  the  posterior  columns  (sensory),  and 
that  because  anterior  poliomyelitis  and  tabes  dorsalis  are,  in  fact, 
lesions  of  the  same  peripheral  neuron  as  motor  and  sensory  peri- 
pheral neuritis  respectively. 

Pathologically  the  difference  lies  in  the  exact  point  in  the 
neuron  where  the  trouble  begins.  This  is  in  the  cells  of  the 
anterior  cornua,  and  of  the  posterior  roots  ^  in  the  system  lesions, 
with  consequent  rapid  secondary  degeneration  of  neuraxons.  While 
in  peripheral  neuritis  the  affection,  if  not  limited  to  the  neuraxon, 
at  least  begins  in  it,  and  only  secondarily  involves  the  neuron  cell 
in  severe  cases.  Clinically  we  are  fortunately  able  to  find  a  good 
many  differences,  so  that  in  the  majority  of  cases  but  little  difficulty 
arises  in  diagnosis  ;  though  it  must  be  confessed  that  often  also  only 
time  and  very  great  patience  will  but  partially  unravel  the  mystery. 

A. — The  Onset 

The  onset  of  the  system  lesions  is,  as  a  rule,  in  marked  contrast 
to  that  of  the  peripheral  troubles. 

Anterior  poliomyelitis  occurs  as  : — 

1.  Acute,  (a)  Idiopathic  infantile  paralysis. 

ij))  „  adult  „ 

{c)  Part  of  an  acute  myelitis. 

2.  Chronic,  or  progressive  muscular  atrophy. 

Sclerosis  of  the  posterior  columns  is,  as  an  idiopathic  affection, 
always  chronic. 

Now,  acute  infantile  paralysis  commences  with  a  sharp  outburst 
of  fever,  and  cannot  be  diagnosed  from  a  zymotic  fever  until  its 
special  symptom,  viz.  paralysis,  has  supervened.  Inasmuch  as  there 
is  a  concomitant  congestion  of  the  spinal  cord,  this  onset  may  be 
associated  with  a  pain  in  the  back,  leading  to  a  suspicion  of  variola 
or  of  meningitis  ;  the  rash  will  soon  differentiate  the  former,  and  the 
latter  will  soon  be  excluded  by  the  subsidence  of  the  pain  and  the 
^  This  is  the  view  now  entertained  of  tabes  dorsalis. 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  293 

very  rapid  appearance  of  the  paralysis;  if  meningitis  were  the  trouble 
the  pain  would  persist  and  the  paralysis  (if  any)  would  be  long 
delayed  until  the  inflammation  had  had  time  to  attack  and  destroy 
neuraxons.  In  adults,  while  the  course  of  events  is  precisely  the 
same,  the  general  symptoms  are  much  less  pronounced,  though  the 
onset  is  equally  rapid ;  still,  the  age  is  in  itself  very  important,  for 
anterior  poliomyelitis  is  as  rare  in  adults  as  a  mysterious,  i.e.  without 
obvious  cause,  neuritis  is  in  children,  and  vice  versa.  On  the  other 
hand,  peripheral  neuritis  rarely,  if  ever,  has  such  an  acute  pyrexial  onset 
with  pain  in  the  back  ;  it  may  have  a  smouldering  fever  lasting  several 
days,  or  even  a  week  or  two  (the  febrile  period  in  poliomyelitis  is  at 
most  three  or  four  days,  generally  only  twenty-four  or  forty-eight 
hours),  but  then  it  has  not  the  pain  in  the  back ;  if  it  has 
the  pain  in  the  back  (lumbago  and  sciatica)  it  will  not  have  the 
pyrexia  unless  this  be  associated  with  definite  joint  (rheumatism 
or  gout)  trouble. 

In  those  cases  in  which  the  acute  poliomyelitis  is  only  part  of 
an  acute  transverse  lesion,  the  early  bladder  and  rectal  disturbance 
and  the  complete  paraplegic  anaesthesia  will  be  sufficient  to  prevent 
mistakes. 

In  the  more  chronic  forms  of  trouble  also  the  onset  presents 
more  striking  differences  than  likenesses.  Thus,  in  a  peripheral 
motor  lesion  there  is  probably  more  wasting  and  paralysis  in  six 
weeks  to  two  months  than  a  case  of  progressive  muscular  atrophy 
will  show  in  six  months  or  a  year;  and,  again,  the  locality  will  be 
different,  for  in  the  neuritis  the  whole  limb,  or  whole  muscles,  will 
have  suffered  (except  in  isolated  nerve  cases,  w^hich  will  probably 
have  an  obvious  local  cause),  whereas  in  progressive  muscular 
atrophy  the  changes  will  be  confined  to  hand  or  foot  (common 
type),  or  to  shoulder  muscles  (upper  arm  type),  spreading  thence 
very  slowly.  The  latter  disease,  progressive  muscular  atrophy,  may 
be  finally  dismissed  by  stating  that  it  has  no  other  nervous  features 
except  a  progressive  weakness  going  hand  in  hand  pari  passu  with 
the  wasting,  and  R.D.  is  not  to  be  obtained  typically;  while  in 
peripheral  neuritis  the  paralysis  is  out  of  all  proportion  in  the 
early  days  to  the  wasting,  and  R.D.  is  typically  present.  The 
reason  for  these  differences  is  obvious  if  we  remember  that  in  the 
system  disease  the  cornual  cells  suffer  one  after  another  in  very 
slow  progression,  and  consequently  individual  neuraxons  with  their 
nutritional  functions  die  and  cause  atrophy  of  individual  muscle  fibres 
or  bundles  ;  while  in  the  peripheral  troubles  many  neuraxons  are 
simultaneously  involved. 


294  DIFFERENTIAL  DIAGNOSIS  chap. 


B. — The  Course  of  Established  Symptoms 

The  system  lesions  in  their  course,  though  sometimes  appar- 
ently standing  still,  rarely  or  never  lose  their  typical  physical  signs 
by  which  they  have  been  diagnosed,  but  they  frequently  show  im- 
provements or  exacerbations  quite  unaccounted  for  by  anything  that 
can  be  called  treatment  or  neglect.  Peripheral  lesions,  on  the  other 
hand,  proceed  almost  steadily  in  one  of  three  directions  :  (i)  straight 
downhill  to  the  grave  in  less  than  a  year  or  eighteen  months;  (2) 
downhill  for  so  long  as  the  cause  acts  and  a  little  longer,  and  then 
with  the  cessation  of  the  cause  (usually  alcohol)  steady  improvement 
sets  in  up  to  complete  recovery,  unless  and  until  the  cause  again 
operates,  when  history  repeats  itself;  (3)  persist  for  an  indefinite 
time  without  any  apparent  alteration.  The  perennial  root  of  the 
tree  is  attacked  in  the  system  lesion  ;  in  the  other  a  branch  is  cut  off 
which  may  or  may  not  grow  again,  but,  on  the  other  hand,  it  may  be  so 
necessary  to  nutrition  that  the  whole  tree  dies. 

We  will  now  conclude  the  subject  of  cord  and  peripheral  troubles 
with  a  few  tables  of  special  interest. 

Peripheral  Neuritis  and  Tabes  Dorsalis 
These  often  have  the  following  in  common : — 

1.  Inco-ordination  of  movement ; 

2.  Pains  in  limbs  ; 

3.  Absent  knee  jerks ; 

but  more  frequently  they  differ  in  the  following : — 

Peripheral  Neuritis.  Tabes  Dorsalis. 

Inco  -  ordination     seldom     a    very     Inco-ordination  especially  marked ; 
marked  feature ;    paralysis   very  paralysis     and     weakness      for 

common.  simple        movements         never 

present. 
Pain  is  in  the  nerve,  never  a  girdle     Pain    shoots  along  a   limb  ;    if  a 
pain.  girdle   pain  present   it   is    very 

strong    evidence    (root    symp- 
tom). 
Paraesthesias  common.  Paraesthesiae  rarely  present 

Knee  jerks  sometimes  exaggerated.      Knee  jerks  never  exaggerated. 
Viscera  never  affected.  Visceral  crises  and  disturbance  of 

function  common. 


VIII 


DISEASES  OF  THE  NEPvVOUS  SYSTEM 


295 


Peripheral  Neuritis. 
Eye  affections  may  be  present;  if  so 
they  are  prominently  complained 
of,  and  may  stand  as  the  sole 
symptoms  ;  optic  neuritis  or 
atrophy  extremely  rare. 


Tabes  Dorsalis. 
Pupillary  or  oculo-motor  troubles 
nearly  constant,  but  in  addition 
to  other  symptoms  ;  atrophy  of 
optic  nerve  frequently  found. 


m- 


Infaniile  Paralysis  will  resemble  Diphtheritic  Peripheral  Neuritis 

(a)  History  of  acute  illness ; 

(b)  Rapid  onset  of  paralysis  ; 

(c)  Some  wasting  of  muscles ; 


but  the  two  will  probably  differ  in — 


Diphtheria. 

Acute  illness  almost  certainly  with 
prominent  local  (throat,  vagina, 
wound,  etc.)  symptoms. 

Paralysis  almost  always  of  eye  or 
palate  first,  and  rarely  of  limbs 
at  all. 

Wasting  not  great,  and  R.D.  typi- 
cally present  only  in  severe 
cases. 

Very  symmetrical  paralysis. 

May  get  worse  for  some  days  after 
onset ;  recovery  is  always  practi- 
cally complete  if  the  patient  does 
not  die. 


Infantile  Paralysis. 

Acute  illness  with  only  general 
symptoms  or  some  pain  in 
spine. 

Almost  always  of  limbs  only,  very 
rarely  cranial  at  all. 

Wasting  considerable,  and  R.D. 
nearly  constant,  in  some  muscles 
at  any  rate. 

Ultimate  paralysis  characteristi- 
cally local  and  asymmetrical. 

After  twenty-four  or  forty-eight 
hours  any  alteration  is  always 
in  the  direction  of  improve- 
ment ;  recovery  is  never  abso- 
lutely complete. 


Ataxic  Paraplegia  v.  Peripheral  Neuritis 

The  combined  motor  and  sensory  phenomena  may  arouse 
suspicion  of  some  peripheral  affection,  but  the  course  of  the  cord 
disease  is  in  itself  almost  sufficient  to  separate  it  from  the  latter ; 
the  cord  trouble  is  always  slow  in  onset,  and  months  elapse  before  it 
advances  fair,  while  the  neuritis  is  almost  invariably  acute  or  sub- 
acute. The  very  marked  inco-ordination,  too,  of  the  cord  trouble, 
especially  taken  with  the  exaggerated  knee  jerk,  adds  further  confirm- 
atory differentiation. 


296  DIFFERENTIAL  DIAGNOSIS  chap. 

Amyotrophic  Lateral  Sclerosis  v.  Peripheral  Neuritis 

Dr.  Gowers  says,  "  The  wasting  from  disease  of  single  nerves  or 
at  a  plexus  is  sufficiently  distinguished  by  its  limitation,  coupled 
with  its  rapid  onset  and  associated  sensory  symptoms  " ;  and  from 
some  forms  of  multiple  neuritis,  he  says,  "  It  is  necessary  to  wait 
for  slower  wasting  in  other  parts  than  those  first  affected  before  a 
diagnosis  can  be  made ;  a  careful  search  will  generally  reveal  other 
symptoms  of  neuritis,  and  a  known  cause  is  usually  obtrusive." 

Lateral  Sclerosis  v.  Peripheral  Neuritis 

Any  affection  of  the  pyramidal  tracts  can  only  be  mistaken  for  a 
case  of  pure  motor  peripheral  trouble.  If  sensory  phenomena  are 
present  to  an  extent  sufficient  to  attract  attention  the  disease  is  not 
primary  lateral  sclerosis.  The  cases  of  motor  neuritis  which  could 
rouse  an  idea  of  lateral  sclerosis  must  be  either  of  arms  or  legs. 
Now,  if  it  be  of  the  arms,  the  note  at  the  bottom  of  p.  287  shows  us 
that  if  the  lateral  columns  are  affected  as  high  as  the  origin  of  the 
brachial  plexus,  the  knee  jerk  is  exaggerated  and  ankle  clonus 
probably  marked ;  but,  per  contra,  the  peripheral  brachial  nerves  have 
no  such  influence  on  the  rest  of  the  cord,  and  there  will  be  no 
disturbance  of  reflexes  lower  down.  The  same  test  will  also  apply 
if  the  trouble  be  in  the  legs,  for,  except  in  the  earliest  stage  of 
neuritis  (and  that  arising  in  a  manner  and  under  circumstances 
which  preclude  all  idea  of  lateral  sclerosis),  the  knee  jerk  is  absent 
and  ankle  clonus  not  to  be  obtained. 

Peripheral  Neuritis  v.  Disseminated  Sclerosis 

Insular  sclerosis  most  usually  offers  a  fairly  typical  symptom 
complex  which  cannot  be  mistaken  for  anything  except  functional 
(or  hysterical)  nervous  disease  ;  but  inasmuch  as  its  very  name 
implies  a  random  distribution,  it  is  possible  that  cases  may  arise  in 
which  the  peripheral  nerves  are  suspected. 

Of  the  many  symptoms  that  may  occur  in  disseminated  sclerosis 
there  are  three  which,  notwithstanding  its  indiscriminate  distribution, 
are  almost  constant,  viz. — 

1.  Intention  tremors  ; 

2.  Nystagmus  ; 

3.  Increased  knee  jerk ; 

and  it  is  as  rare  to  find  a  case  of  peripheral  neuritis  exhibiting  these 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


297 


three  in  combination  without  other  obvious  indications  as  it  is  to 
find  a  case  of  disseminated  sclerosis  in  which  they  are  not  all  three 
present. 

Disseminated  Sclerosis  v.  Hysteria  or  Functional 

Troubles 

To  distinguish  the  early  stages  of  sclerosis  from  what  is  usually 
accepted  as  functional  disease  is  probably  to  try  and  make  a  distinc- 
tion between  identicals,  for  the  death  of  neurons  by  sclerosis  is  in 
all  probability  preceded  by  a  stage  of  functional  debility  in  which 
recovery  is  certainly  possible,  but  as  the  recognition  and  demon- 
stration of  this  recoverable  condition  is  all-important  from  a  thera- 
peutical and  prognostic  point  of  view,  I  have  drawn  up  the  following 
table  of  points  most  worthy  of  attention  in  rough  order  of  im- 
portance. 


Functional. 

Tremors  very  common,  but  not 
so  violent  as  to  prevent  comple- 
tion of  intention. 

Nystagmus  very  rare  and  ill- 
marked  ;  double  vision  rare 
except  very  temporary. 

Knee  jerks  probably  glib,  but 
variable  from  time  to  time. 


4.  Speech     probably     voluble,     or     4. 

obstinate  silence;  seldom 
scanning,  varies  from  time  to 
time. 

5.  If   bladder    trouble    at   all   it    is 

retention,  and  pain  not  com- 
plained of. 

6.  Optic     neuritis    or    atrophy    un- 

known. 

7.  Recovery    rather     sudden     and     7 

complete,  and  possibly  no  return ; 
if  return  it  is  sudden  and  in  the 
same  guise. 

8.  Sensory    hemi  -  anaesthesia     not     8 

uncommon  with  recovery. 


Established  Disseminated  Sclerosis. 

1 .  Tremors  so  violent  as  frequently 

to  quite  frustrate  intention. 

2.  Nystagmus   common   and  very 

distinct ;  double  vision  not 
uncommon. 

3.  Knee  jerks  grossly  exaggerated 

and  invariable  \  should  a 
patch  have  caught  the  reflex 
chain  they  will  be  absent,  but 
still  invariable. 

Speech   scanning   usually,    and 
not  variable. 


5.  Bladder  trouble  frequent  ;  in- 
continence, stammering  blad- 
der, and  even  painful  retention. 

6.  Optic  atrophy  if  present  is 
conclusive,  for  it  is  sclerosis. 

7.  Apparent  recovery  curiously 
frequent,  but  return  of  symp- 
toms soon  occurs  ;  may  be  in 
another  guise. 

Hemi  -  anaesthesia  rare,  and 
what  anaesthesia  occurs  is 
little  likely  ever  to  be  removed. 


298  DIFFERENTIAL  DIAGNOSIS  chap. 

Functional.  Established  Disseminated  Sclerosis. 

9.    Perversion  of  will  power  a  fre-  9.   Perversion  of  will  power  not 

quent  cause,  or  concomitant,  often  observed  to  any  extent ; 

and  very  variable  at  times.  if  it  is  present  it  remains. 

10.  Spasticity  and    inco-ordination  10.    If  spasticity   or   inco-ordina- 

variable  from  time  to  time.  tion  occurs  it  is  likely  to  be 

permanent. 

11.  If  any    wasting    occurs    it    is      li.    If  wasting   occurs  it  is  likely 

likely  to  be  general,  and  very  to     be     local     and     fairly 

slow  in  onset,  and  arises  from  rapid,  though  when  lateral 

mere  disuse.  columns    are    affected    this 

will  not  hold. 


AFFECTIONS  OF  MEDULLA,  PONS,  AND 
CEREBELLAR  PEDUNCLES 

In  dealing  with  the  peripheral  nerves  and  spinal  cord  I  have 
dealt  at  some  little  length  with  the  points  of  differential  diagnosis 
because  the  cases  are  more  commonly  met  with,  and  because 
the  problems  of  diagnosis  are  comparatively  simple  in  themselves 
if  due  attention  is  paid  to  the  elements  that  lead  to  conclusions. 

In  dealing  with  intracranial  troubles  we  are  introduced  at  once 
to  so  much  that  is  absolutely  unknown,  and  still  more  that  is  only 
guessed  at  or  in  dispute,  as  regards  anatomy  and  physiology,  that 
complete  diagnosis  is  frequently  impossible,  and  I  shall  only 
attempt  to  sketch  a  clear  outline  of  the  principles  of  regional  and 
pathological  diagnosis,  and  introduce  independently  a  few  important 
subjects  which  are  but  ill  remembered  and  worse  understood  by 
students. 

An  accurate  knowledge  of  the  precise  regional  relations  of  the 
various  tracts  of  fibres  and  groups  of  cells  whose  functions  are  more 
or  less  known  is  absolutely  essential  for  a  clear  understanding  of 
the  diagnostic  problems  offered  by  disease  in  this  region.  The 
best  way  to  learn  this  is  by  careful  study  of  sections  compared  with 
the  figures  to  be  found  in  every  text-book  of  anatomy.  They  may 
be  tabulated  for  study  thus  : — 

Fibres  of  Pons,  Medulla,  and  Cerebellar  Peduncles 
A. — Old  Tracts  already  noticed  in  the  Cord 

I.   Pyramidal,  cross-     Constitute  the  crossing  of  the  pyramids,  and  then 
ed    and    direct ;         the  pyramidal  tracts  through  the  medulla,  pons. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


299 


functions  purely 
motor. 


Antero  -lateral 
ascending  tract  ; 
function  to  con- 
vey centripetal 
impulses. 
Direct  cerebellar 
tract ;  function 
centripetal  (?  en- 
tirely). 

Posterior  col- 
umns :  function 
centripetal. 
Bulk  of  unnamed 
white  fibres  of 
cord,  function 
nearly  or  quite 
unknown  unless 
commissural. 


and  cerebral  "crura."  In  tracing  these  down 
from  the  motor  cortex  it  must  be  noted  that 
some  of  them  turn  out  to  join  the  nuclei  of 
origin  of  the  motor  cranial  nerves,  in  which 
case  the  relationship  between  cortex  and  nucleus 
is  always  crossed^  precisely  the  same  as  that  of 
cortex  and  anterior  comua  of  cord. 

Some  are  traceable  as  fibres  in  the  formatio 
reticularis,  reaching  thus  the  superior  cere- 
bellar peduncles  and  so  the  cerebellar  cortex  ; 
others  are  lost  in  the  formatio  reticularis,  and 
their  further  course  unknown. 

Form  a  large  part  of  the  restiform  bodies  or 
inferior  peduncles  of  cerebellum.  This  is  the 
only  known  ending  of  these  fibres. 

End  in  synapses  with  the  cells  of  the  funiculi 
gracilis,  cuneatus,  and  rolandi. 

Constitute  probably  the  bulk  of  the  fibres  of  the 
formatio  reticularis.  Their  destination  is  un- 
known and  also  their  function,  though  they  are 
assumed  to  unite  successive  segments  of  the 
mid-brain. 


B. — New  Tracts  of  Fibres^  or  in  some  cases  New  Names  for  Old  Tracts 

Originate  in. 
I.   {a)   Cells  of  nuclei  gracilis, 
cuneatus,  and  rolandi. 


{U)   Unnamed  white  fibres 
of  cord. 


ic)  Olivary  body  and  other 
cells  in  the  region  of 
the  upper  medulla. 

2.  Direct  cellebellar  tract  of 
cord,  internal  and  external 
arcuate  fibres. 


Tract.  Reaching  to. 

{a)  Function   afferent,  reach- 
ing the  inferior  peduncles 

.S2  of  cerebellum    as    inter- 

^  nal  arcuate  fibres,  pass- 

o  ing  to  cerebellar  cortex, 

t)  {b)  Reach  cortex  of  cerebrum 

o  and  cerebellum,  or  end 

t5  in  cells  of  formatio  reti- 

S  cularis  {vide  5  above). 

<2  id)  Many  go  as  arcuate  fibres 

Q  to  cerebellum,  many  also 
of  unknown   destination 

u,  ^    ■  and  function. 


.2  ^  ^ 


Cerebellar  cortex  and  nuclei. 


300 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


Originate  in. 

3.  Cells     of     nuclei    gracilis, 

cuneatus,  and  rolandi,  also 
independent  cells  in  for- 
matio  reticularis,  and 
many  of  cells  of  the 
olivary  body. 

4.  Begins  by  axons  from  cells 

of  nuclei  gracilis,  cuneatus, 
and  rolandi,  added  to  by 
axons  from  cells  of  for- 
matio  reticularis,  of  oli- 
vary body,  etc. 

5.  Cells  of  reticular  formation 

at  one  end,  cells  near  the 
nucleus  of  third  nerve  at 
the  other,  and  from  inter- 
mediate cells. 


6.   From   cortex  of  one  cere- 
bellar hemisphere. 


Tract. 


(U 

u 


<L) 


o   a 

u    d 
O     13 

'-'    o 

>     CO 


Reaching  to. 

Functions  probably  afferent, 
reaching  cerebellar  cortex 
by  inferior  peduncles. 


Is  the  principal  afferent  (? 
entirely)  passage  to  brain 
from  the  cells  in  medulla, 
reaching  to  corpora  quad- 
rigemina  and  optic  thala- 
mus. 

Probably  motor  in  function, 
serving  for  connections 
between  motor  cranial 
nerves,  especially  in  their 
associated  (quasi  -  reflex) 
movements,  e.g.  lips  and 
tongue,  the  two  eyes,  etc. 

To  the  other  hemisphere, 
probably  engaged  in  co- 
ordination. 


Of  funiculi — 

Form 

Gracilis, 

f(^) 

Cuneatus, 

i(^) 

Rolandi, 

((^) 

In  formatio — 

Form 

Reticularis. 

((^) 

\  (A 

Cells      of      cranial 

Form 

nerves  from  three 

to  twelve. 

Cells  of  the  region 


some  of  the  neuraxons  of — 

Fillet. 

Internal  arcuate  fibres. 

Others  of  unknown  destination. 

neuraxons  going  to — 

Reinforce  fillet. 

Connect  different  segments. 

External  arcuate  fibres. 

Reinforce  posterior  longitudinal  bundle. 

the  neuraxons  of  their  respective  nerves. 


Now,  in  applying  these  facts  of  anatomy  and  physiology  to  the 
problems  of  diagnosis,  it  cannot  be  too  strongly  insisted  upon  that 
in  intracranial  lesions,  just  as  in  peripheral  (and  cord)  ones,  there  is 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  301 

nothing  essentially  mysterious  or  beyond  the  power  of  the  youngest 
student  to  grasp.  The  mystery,  so  far  as  there  is  any,  lies  simply 
and  solely  in  our  ignorance  of  the  exact  path  of  nerve  impulses, 
and  of  the  amount  and  nature  of  control  and  interference  exercised 
by  one  neuron  group  over  another.  Lesions,  of  whatever  nature, 
affect  the  structure  and  function  of  individual  neurons  in  precisely 
the  same  way  here  as  elsewhere,  and  this  affection  (whether  of 
defect  or  excess)  it  is  that  constitutes  our  means  of  localising 
diagnosis. 

The  elementary  facts  to  grasp  are : — 

1.  That  every  anatomical  nerve  in  the  body  has  the  power  of 
communicating  with,  or  of  receiving  messages  from,  the  cortex  of 
cerebrum  and  cerebellum  for  purposes  of  harmonious  functioning  in 
the  healthy  body. 

2.  That  for  some  reason  (several  explanations  of  the  fact  have 
been  offered)  that  portion  of  the  cerebral  cortex  which  is  thus  in 
connection  with  a  peripheral  nerve  is  in  the  opposite  named  (right 
or  left)  hemisphere  to  that  side  in  which  occurs  the  peripheral  dis- 
tribution of  the  nerve  in  question. 

3.  That,  per  contra^  the  relationship  of  the  cerebellar  cortex  to  a 
nerve  is  an  uncrossed  one. 

4.  That  this  crossing  of  impulses  and  of  fibres  lies — 

A.  For  motor  nerves  and  impulses — 

{a)  In  the  lower  part  of  the  medulla,  so  far  as  spinal 

nerves  are  in  question. 
ip)  For  the  cranial  nerves,  just  a  little  nearer  to  the 

cortex  than  the  nuclei  of  origin. 

B.  For  sensory  nerves  and  impulses — 

{a)  Distributed  throughout  the  cord  and  medulla  for 
the  spinal  ones,  each  nerve  crossing  at  once. 

(3)  For  the  cranial  nerves,  just  a  little  nearer  the 
cortex  than  the  nuclei  of  origin. 

5.  It  is  at  once  an  obvious  and  necessary  deduction  from  these 
elements  of  crossed  influence  that  a  lesion  of  a  strand  of  fibres 
above,  i.e.  nearer  the  cortex  cerebri  than  the  nucleus  of  origin  of  the 
peripheral  nerve  in  question,  must  exhibit  its  effects  on  the  opposite 
side  of  the  body  to  that  on  which  the  lesion  lies.  If  it  be  at,  or  on 
the  peripheral  side  of,  the  nucleus,  its  effects  must  be  exhibited  on 
the  same  side  as  that  of  the  lesion ;  and  further,  from  what  has 


302  DIFFERENTIAL  DIAGNOSIS  chap. 

been  said  on  p.  252  about  the  function  of  the  neuron  cell,  must 
almost  inevitably  be  associated  with  some  trophic  alteration  (excess 
or  defect)  in  the  muscles  affected. 

6.  A  self-obvious  statement,  but  one  too  frequently  forgotten, 
that  the  closer  the  nerve  fibres  (or  cells)  lie  together  the  more  likely 
are  they  to  be  involved  together  by  a  small  lesion.  In  this  fact, 
however  elementary  it  may  seem,  lies  the  clue  to  at  least  one-half 
of  the  localising  problem.  Thus,  taking  the  motor  side  and  a 
destructive  lesion  as  an  illustrative  example,  a  cortical  or  sub- 
cortical small  lesion  may  easily  be  understood  to  be  capable  of 
producing  a  monoplegia,  but  the  nearer  we  get  to  the  (anterior  two- 
thirds  of  the  posterior  limb  of  the)  internal  capsule,  the  more  fibres 
will  be  caught  by  the  lesion,  and  the  wider  will  be  the  peripheral 
area  of  disturbance,  until  when  we  arrive  at  the  crura  cerebri,  pons, 
and  medulla  the  motor  fibres  are  collected  so  closely  together  that 
it  is  almost  impossible  but  that  a  paralysis  shall  be  at  least  a  hemi- 
plegia, and  possibly  even  a  complete  paralysis  of  all  four  limbs. 
Further,  speaking  of  our  present  region — the  mid-brain — it  is  almost 
impossible  but  that  some  at  least  of  the  motor  cranial  nerves  shall 
have  participated  in  the  disturbance;  for  this  reason  they  give  us 
tolerably  exact  information  of  the  locality  of  the  trouble.  This 
will  at  once  explain  the  following  clinical  experience,  viz.  that  given 
a  hemiplegia^  then  if  it  is  due  to  a  lesion — 

In  CPUS  Cerebri. — The  third  nerve  on  the  opposite  side  is  nearly 
sure  to  be  paralysed.  Any  other  cranial  paralysis  will  be  on 
the  same  side  as  the  paralysis  of  the  body. 

In  Upper  Pons. — We  may  look  for  some  weakness  in  the  opposite 
fifth  nerve  (motor  part),  and  possibly  some  anaesthesia, 
though  there  is  a  considerable  distance  between  the  motor 
pyramidal  fibres  and  the  sensory  root  of  the  fifth. 

In  Lower  Pons. — Very  probably  a  paralysis  of  the  opposite 
seventh,  because  its  peripheral  course  lies  so  close  to  the 
motor  fibres  which  are  destroyed.  (The  explanation  of  the 
contraction  of  the  pupils,  a  constant  feature,  is  not  quite  so 
obvious.) 

In  Medulla. — We  may  look  out  for  a  paralysis  of  the  opposite 
sixth,  very  possibly  of  the  opposite  seventh,  because  the 
seventh  nerve  winds  round  the  sixth  nucleus.  (A  paralysis 
of  both  sixth  nerves  is  not  such  a  precise  indication,  owing 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  303 

to  their  exposure  to  pressure  between  the  pons  and  the 
bone.)  In  the  lower  part  of  the  medulla  one  twelfth  nerve 
or  a  spinal  accessory  is  very  likely  to  be  affected,  leading  to 
deviation  of  protruded  tongue,  or  to  paralysis  of  a  vocal 
cord. 


CRANIAL  NERVES 

The  last  paragraph  has  shown  the  importance  of  these  nerves  as 
indicators  of  locality  of  a  lesion.  I  propose  now  to  add  a  few  notes 
on  the  individual  nerves  and  their  lesions. 

Firsts  or  Olfactory. — This,  strictly  speaking,  is  not  a  nerve  but  an 
integral  part  of  the  cerebral  cortex.  Chnically,  if  the  sense  of  smell 
is  impaired,  we  must  first  suspect  and  investigate  the  external 
cavities.  Tf  these  are  declared  free  from  suspicion  the  trouble  may 
be  situated  in  the  anterior  fossa  of  the  skull,  causing  pressure  on 
the  olfactory  bulbs.  The  cortical  connections  of  the  bulbs  are 
supposed  to  exist  in  the  tip  of  the  temporo-sphenoidal  lobe,  so  that 
in  cases  of  suspected  abscess  or  tumour,  interference  wdth  the 
faculty  of  smell  is  a  suggestion  that  the  lesion  is  not  far  from  that 
situation. 

Second^  or  Optic. — Like  the  olfactory,  is  a  distinct  outgrowth  of 
the  brain,  with  a  primary  connection  with  the  corpora  quadrige- 
mina.  Its  cortical  representation  is  found  {a)  in  the  occipital  lobes 
for  coarse  optical  impressions,  i.e.  for  an  appreciation  of  the  fact 
that  something  is  affecting  the  optic  nerves;  {b)  in  the  supra- 
marginal  and  angular  gyri  round  the  end  of  the  sylvian  fissure  for 
optical  perceptions  and  judgments,  i.e.  for  an  appreciation  of  the 
precise  object  that  is  stimulating  the  optic  nerves,  and  its  exact 
nature  and  associations.  Hence,  as  regards  localising  deductions 
from  the  nerve,  we  have — 

{a)  Optic  neuritis  {vide  p.  324). 

lb)  If  hemianopia  be  due  to  a  lesion  of  the  optic  tracts  the 
pupil  will  not  react  when  light  is  thrown  on  the  blind 
half  of  the  retina,  because  the  lesion  is  in  front  of  the 
centre  for  reflex  of  light ;  if  it  lies  between  the  corpora 
quadrigemina  and  the  optic  lobes  the  pupil  will  react, 
but  the  patient  will  not  perceive  that  anything  is  stimu- 
lating the  retina ;  if  the  lesion  is  between  the  occipital 
and  the  supramarginal  lobes  he  will  perceive  the  object, 


304  DIFFERENTIAL  DIAGNOSIS  chap. 

but  will  not  judge  its  nature  correctly.  (This  is  the 
condition  known  as  word  blindness  when  testing  a  case 
of  aphasia.) 

Thirds  JFourth,  and  Sixth.  —  These  nerves,  taken  collectively, 
form  the  motor  apparatus  (with  muscles)  of  the  eye-balls,  built  and 
arranged  to  subserve  the  purpose  of  single  vision  with  two  eyes,  for 
which  very  accurate  associated  action  of  the  muscles  is  required. 
This  is  provided  for  undoubtedly  by  the  close  approximation  of  the 
nuclei  of  the  nerves,  and  by  the  posterior  longitudinal  bundle 
serving  as  a  rapid  means  of  communication;  hence  it  certainly 
follows  that  nuclear  lesions  of  these  nerves  or  of  the  posterior 
longitudinal  bundle  will  cause  squinting,  or  at  least  double  vision 
(squint  is  merely  a  deviation  of  the  visual  axes  from  their  normal 
position  visible  to  the  observer).  Such  lesions  are  known,  though 
not  very  common ;  their  exact  discussion  would  be  too  intricate  to 
follow  out  here.  It  must  not  be  forgotten  that  these  three  nerves 
lie  very  close  to  one  another  and  to  the  orbital  branch  of  the  fifth 
at  the  entrance  to  the  orbit,  so  that  a  tumour  or  sclerosing  lesion  in 
that  situation  may  produce  a  total  paralysis  of  all  four  nerves. 

Simpler  problems  are  presented  by  considering  the  individual 
nerves  and  their  branches,  i.e.  peripheral  lesions. 

Ihird  Nerve. — If  affected  by  a  crural  lesion  it  is  probable  that 
there  will  be  a  complete  paralysis  of  the  whole  of  the  third  on  the 
opposite  side  to  that  on  which  the  paralysis  of  the  body  is  said  to 
be.  If  affected  in  the  more  peripheral  parts  of  its  course,  it  is  more 
probable  that  the  paralysis  will  be  incomplete,  i.e.  of  one  or  more 
branches  only.  The  reason  for  this  is  better  discussed  along  with 
pathological  diagnosis. 

Fourth. — To  this  nerve  the  same  remarks  apply  as  to  the  third, 
remembering  that  it  only  supplies  one  muscle,  viz.  the  superior 
oblique,  which  assists  in  downward  m.Qis&v[).^xi\.'^  of  the  globe.  Hence 
double  vision  on  looking  downwards  only. 

Fifth. — When  affected  at  or  above  its  nucleus  never,  according 
to  Bastian,  exhibits  trophic,  vasomotor,  or  secretory  disturbances  of 
function ;  when  affected  in  its  peripheral  course  does  exhibit  such 
disturbances  in  the  appropriate  area  of  distribution. 

Sixth. — As  above  remarked,  the  exposed  position  of  these  nerves 
between  the  pons  behind  and  the  bone  in  front  deprives  a  double 
paralysis  of  much  locahsing  value,  but  if  one  only  is  affected  we  have 
strong  ground,  in  an  otherwise  doubtful  case,  for  believing  that  the 


vin  DISEASES  OF  THE  NERVOUS  SYSTEM  305 

lesion  is  in  the  medulla  or  in  front  of  the  pons ;  in  front,  that  is,  as 
regards  the  cranial  fossae.  If  one  sixth  and  the  same  named  (right 
or  left)  seventh  are  involved  together,  we  can  fix  the  lesion  pretty 
accurately  as  at  that  spot  in  the  medulla  where  the  seventh  nerve 
winds  round  the  sixth  nucleus. 

Seventh. — In  small  lesions  at  or  above,  i.e.  nearer  the  cortex,  its 
nucleus,  it  is  a  clinical  fact  that  the  occipito-frontalis  muscle  almost 
invariably  escapes,  probably  because  the  muscle  is  most  commonly 
used  reflexly,  and  stimuli  reach  it  by  the  posterior  longitudinal 
bundle.  If  the  nerve  is  affected  between  the  brain  and  the  bottom 
of  the  internal  auditory  meatus  it  is  very  likely  that  deafness  of  the 
same  ear  may  be  found,  because  the  seventh  nerve  lies  in  actual 
contact  with  the  eighth.  In  lesions  beyond  this  point,  up  to  the 
exit  from  the  stylomastoid  foramen,  it  is  likely  that  the  paralysis  will 
be  absolutely  complete.  Beyond  this  point  individual  branches 
may  be  caught  by  a  lesion,  but  we  shall  have  probably  gross  mani- 
festations of  a  swelhng  (parotitis,  etc.)  or  inflammation  to  help  us 
outside  the  skull.  It  is  also  to  be  noted  that  in  peripheral  lesions 
there  will  be  no  associated  hemiplegia. 

Eighth. — In  central  lesions  it  is  not  likely  that  the  auditory 
nerve  will  suffer  alone,  its  nuclei  are  too  wide  spread.  In  peripheral 
lesions  it  will  be  likely  to  suffer  alone,  or,  as  above  noted,  in  con- 
junction with  the  seventh  only  of  the  same  side. 

Ninths  Tenth,  and  Eleventh. — Individual  lesions  of  any  of  these 
nerves  alone  at  their  nuclei  are  excessively  rare.  A  central  lesion 
of  any  of  them  will,  therefore,  locate  itself  in  the  medulla  by  being 
associated  with  an  affection  of  all  three.  A  peripheral  lesion  will 
define  itself  by  features  external  to  the  skull. 

Twelfth. — The  tongue  is  so  intimately  connected  with  the  power 
of  articulate  speech  as  to  lead  to  a  conclusion  that  the  cortical 
representation  of  the  twelfth  nerve  is  to  be  found  in  Broca's  con- 
volution on  the  left  side,  and  in  a  corresponding  area  on  the  right 
hemisphere  j  and  we  find  that  a  lesion  on  the  left  side  (?  on  the 
right  side  in  left-handed  people)  in  Broca's  convolution,  or  between 
it  and  the  twelfth  nuclei,  disarranges  the  function  of  the  tongue  so 
far  as  that  subserves  speech  (pure  motor  aphasia). 

Again,  in  deglutition,  and  in  practically  all  uses  of  the  tongue, 
the  two  halves  are  so  accustomed  to  work  together  that  it  would 
seem  a  great  convenience  (or,  probably,  almost  a  necessity)  that 
they  should  be  capable  of  being  stimulated  from  either  side  of  the 

X 


3o6  DIFFERENTIAL  DIAGNOSIS  chap. 

brain.  Furthermore,  as  a  matter  of  anatomical  fact,  the  nuclei  of 
the  right  and  left  twelfth  nerves  lie  so  close  together  in  the  floor  of 
the  lower  half  of  the  fourth  ventricle  as  to  be  almost  intermixed. 
Hence,  as  a  matter  of  clinical  experience,  we  find  that  (barring 
speech  defects)  in  lesions  above  the  nuclei,  if  a  one-sided  paralysis 
of  the  tongue  occurs,  it  is  likely  to  be  incomplete  and  also  to 
be  comparatively  temporary,  and  certainly  unassociated  with  any 
trophic  lesions.  In  lesions  at  the  nuclei  the  paralysis  is  almost 
sure  to  be  bilateral,  and  {vide  p.  252)  associated  with  atrophy. 
From  lesions  peripheral  to  the  nucleus  we  may  again  get  a  one- 
sided paralysis,  but  this  time  with  trophic  lesions. 


DISEASES  OF  THE  BRAIN 

What  we  know  about  the  brain  is,  that  it  is  composed  of  neurons 
and  supporting  (mechanical  and  nutritional)  tissue.  The  former 
so  arranged  and  connected  as  to  subserve  in  the  best  possible 
manner  the  great  purpose  of  bringing  us  into  more  or  less  har- 
monious communication  with  the  world  at  large — co-ordination  of 
functions  in  the  very  widest  meaning  of  the  word.  Here  resides 
the  consciousness  of  change  in  the  environment,  both  internal,  of 
organs,  and  external,  of  the  body,  and  here  is  initiated  the  necessary 
process  to  adapt  everything  to  that  change. 

What  we  hypothecate  is,  that  through  these  neurons,  and  their 
synapses  with  one  another,  messages  can  with  very  great  ease 
pass  from  one  hemisphere  to  the  other  (commissural  fibres), 
or  from  every  part  to  every  part  of  the  hemisphere  of  the  same 
side  (internuncial  fibres),  and  also  with  both  direct  and 
crossed  influence  from  cerebral  to  cerebellar  cortex  and  me- 
chanisms. 

To  completely  analyse  the  tracks  by  which  this  is  done — even 
those  which  are  tolerably  well  known — would  require  a  large  volume, 
and  would  in  the  present  work  serve  no  useful  purpose.  So  far  as 
bedside  diagnosis  is  concerned,  the  principal  difficulties  in  the  way 
of  accuracy  are :  (i)  want  of  precise  knowledge  of  actual  structural 
continuity  of  tract  with  tract;  (2)  a  still  greater  lack  of  precision  in 
knowledge  of  functional  continuity;  (3)  the  fact  that  direct  patho- 
logical lesions,  and  still  less  their  effects  as  regards  pressure,  so 
very  seldom  confine  themselves  to  those  individual  tracts,  or  tracks, 
about  which  we  think  we  know  something. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


307 


The  following  tables  give  some  of  the  principal  points  of  localisa- 
tion, either  approximately  proved  or  strongly  suggested : — 


Cortex  of  the  Brain — 
Ascending  parietal,  as- 
cending frontal,  and 
corresponding 
median  cortex. 


Frontal. 


Occipital. 


Supramarginal  and  an- 
gular. 


Superior     temporo- 
sphenoidal. 

Tip    of    the    temporo- 

sphenoidal  lobe. 
The  rest  of  the  cortex. 

Cortex     of     Cere- 
bellum. 


Possess  the  function  of  initiating  the  motor 
side  of  i?wve?nents  in  various  parts  of  the 
body  on  the  opposite  side.  In  this  area 
of  cortex  are  represented  in  order  from 
above  downwards  the  foot,  leg,  arm, 
face,  so  that  a  pure  cortical  destructive 
lesion  produces  weakening  of  these  move- 
ments. For  irritative  lesions,  vide  Jack- 
sonian  Epilepsy,  p.  309. 

Suggestively  the  seat  of  connected  thought 
and  reasoning ;  lesions  here  have,  in  some 
cases  at  least,  impaired  this  power,  e.g. 
general  paralysis  of  the  insane.  In- 
dubitably this  region  comes  into  structural 
continuity  with  the  anterior  limb  of  the 
internal  capsule,  and  so  functionally  is 
supposed  to  be  connected  with  the  cere- 
bellar and  occipital  cortex. 

Probably  in  the  main  the  seat  of  subjective 
consciousness  of  sensory  stimuli  ;  it  is 
almost  certainly  proved  also  to  be  the 
seat  of  the  primary  registration  of  optic 
impressions. 

Proved  almost  conclusively  to  be  the  seat  of 
the  final  registration  of  optic  impressio^is, 
i.e.  visual  concepts  as  opposed  to  mere 
percepts,  and  to  be  for  this  purpose  in 
close  connection  with  speech  (on  its 
motor  side)  and  appropriate  common 
motor  areas.  These  facts  are  such,  at 
least,  for  the  left  hemisphere  {vide  Optic 
Ner\'e). 

Stands  in  precisely  the  same  relation  to 
auditory  stimuli  that  the  supramarginal 
does  to  visual  ones  {vide  Auditory). 

Represents  the  olfactor}'-  sense  in  a  similar 
though  perhaps  less  efficient  manner. 

Very  few  or  no  facts  essentially  proving  a 
local  or  definite  function. 

All  we  can  say  about  this  is,  that  when, 
by  damage    to   its   peduncles,   messages 


3o8  DIFFERENTIAL  DIAGNOSIS  chap. 

are  unable  to  reach  the  cortex,  defects 
of  equilibration  become  a  marked  feature 
in  the  disease,  but  we  cannot  say  more 
precisely  how  or  why  these  are  caused. 

White  Matter  underlying  Cortex — 

Inasmuch  as  this  is  engaged  in  carrying  messages  to  and  from 
the  cortex,  it  is  difficult,  or  even  in  many  cases  impossible,  to 
differentiate  lesions  of  it  from  those  of  the  overlying  gray  matter. 
All  that  can  be  said,  in  general  terms,  is,  that  the  nearer  to  the 
cortex  the  more  likely  is  subjective  consciousness — apart  from  a 
mere  unconsciousness  in  the  ordinary  sense  of  the  word — to  be 
implicated  in  the  pathological  disturbance,  and  on  the  motor  side 
the  less  likely  are  we  to  get  mere  twitching  (or  loss  of  power)  in 
groups  of  muscles  as  opposed  to  actual  purposive  (but  unconscious) 
movements  or  weakening  of  such  movements.  We  know  a  little 
about  some  tracks,  or  tracts,  in  the  white  matter.     Thus : — 

That  in  the  frontal  lobes  is  collected  mainly  into  the  anterior 
limb  of  the  internal  capsule.  We  do  not  know  much  about  lesions 
of  this,  except  that  we  should  expect  inco-ordination  of  movement 
to  some  extent,  and  incoherence  of  thought,  i.e.  we  only  know  it  so 
far  as  we  know  the  function  of  the  frontal  cortex. 

That  corresponding  to  the  motor  cortex  is  gathered  together  as 
the  corona  radiata,  and  then  more  concentrated  still  in  the  anterior 
two-thirds  of  the  posterior  limb  of  the  internal  capsule.  As  it 
conveys  the  motor  impulses  lesions  of  it  will  cause  hemiplegia  or 
hemiconvulsions. 

That  corresponding  to  the  occipital  cortex  conveys  impressions 
to  the  sensorium  from  everywhere,  per  the  posterior  third  of 
the  posterior  limb  of  the  internal  capsule,  and  lesions  should 
produce  hemianaesthesia  and  lesions  of  sight  corresponding  to  what 
has  already  been  said  on  that  subject :  also  interference  with  the 
afferent  impulses  necessary  for  co-ordination. 

That  of  corpus  eallosum  can  only  be  said  to  connect  the  two 
hemispheres  ;  of  its  special  function,  and  of  evidence  of  its  lesions, 
we  can  say  nothing  here. 

Basal  Ganglia  with  their  Fibres  and  Cells — 

Of  the  corpus  striatum,  optic  thalamus,  and  cells  of  the  teg- 
mentum of  the  crura  cerebri,  it  is  impossible  to  say  anything 
definite  without  going  into  minute  detail.  We  recognise  in  them 
anatomically  complete  neuron  groups  (cells  and  processes)  in  very 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  ^         309 

intimate  connection  with  one  another  and  with  cortical  groups 
— evidently  very  complex  and  delicate  mechanisms  for  the  rapid 
distribution  and  adjustment  of  nerve  stimuli ;  but,  notwithstanding 
the  attention  they  have  received  of  late,  we  are  still  almost  as  much 
in  the  dark  now  as  ever  we  were  as  to  the  precise  part  played  by 
theiTi  in  conscious,  or  in  reflex  life.  We  can  still  only  say  that  the 
corpus  striatum  probably  has  something  to  say  to  the  correct  adap- 
tation of  means  to  ends  on  the  motor  side,  while  the  optic  thalamus 
and  tegmentum  play  a  similar  role  in  connection  with  the  correct 
appreciation  of  afferent  stimuli  on  their  way  to  the  cortex.  Of  the 
corpora  quadrigemina  and  gray  matter  in  connection  with  them  we 
can  say  that  they  play  a  conspicuous  part  in  the  correct  manipulation 
of  the  eyes,  including  in  that  term  not  only  gross  movements  but 
also  accon;modation  and  reflex  to  light. 

We  may  now  conclude  this  elementary  outline  of  localisation  of 
the  brain  functions  by  a  note  on  one  or  two  points  of  special  diag- 
nostic interest  as  illustrations. 

ON  THE  MOTOR  SIDE 

A. — Jacksonian  Epilepsy — 

This  term  has  been  given — in  honour  of  the  first  accurate  investi- 
gator of  the  phenomena — to  attacks  of  convulsive  movements  which 
commence  locally  in  an  extremity,  or  in  the  face,  and  are  due  to  an 
irritant  lesion  of  some  kind  in  that  portion  of  the  rolandic  (or  motor) 
area  corresponding  to  the  given  peripheral  commencement  of  the 
movements.  Any  given  attack  may  be  quite  local,  and  limited  in 
distribution  almost  to  the  spot  originally  attacked,  or  it  may  be 
spread  more  and  more  widely  so  as  to  involve  the  other  limbs 
of  the  same  side,  and  even  those  of  the  other  half  of  the  body,  and 
may  even  end  in  unconsciousness,  hence  it  may  closely  resemble 
idiopathic  epilepsy.  The  important  points  to  remember  about  it 
are,  that  for  the  same  patient — • 

(a)  It  invariably  begins  in  the  same  place  (thumb,  great  toe,  and 
mouth  are  the  commonest). 

{h)  It  invariably  spreads  in  the  same  direction,  though  not 
necessarily  to  the  same  extent ;  the  extent  apparently 
depends  upon  the  nature  and  amount  of  the  te??iporary 
exciting  cause  of  extra  activity,  but  the  direction  is  prob- 
ably governed  by  lines  of  least  resistance,  which  soon 
become  established  in  any  patient,  and  remain  constant  for 
that  patient. 


310  DIFFERENTIAL  DIAGNOSIS  chap. 

{c)  It  is  always  followed  by  an  (at  least  temporary)  paralysis  of 

the  convulsed  muscles  which — 
{d)  Is  always  most  marked  in  the  muscles  first  affected. 

Thus  its  presence  Is  a  very  strong  piece  of  localising  evidence 
for  an  irritant  in  a  particular  part  of  the  rolandic  region.  In  the 
above  particulars  it  may  closely  resemble  idiopathic  epilepsy,  especi- 
ally if  the  aura  of  the  latter  is  local,  but  the  following  points  will 
usually  serve  to  distinguish  them : — 

Jacksonian.  Idiopathic. 

1.  Inmost  cases  either  a  marked     If  cause  be  present  it  will  be  in  the 

and      obvious     cause,     e.g.  shape  of  a  family  history  or  some- 

traumatism,      or      evidence  thing    general,    not    local.        Ab- 

suggestive  of  a  neoplasm  as  sence  of  evidence  of  gross  intra- 

cause.  cranial    disease    other    than    that 

afforded  by  the  fit. 

2.  The    commencement    always     Onset  not   often  local  in  the  situa- 

local,   and    movement    pre-  tions  chosen  by  Jacksonian  ;  when 

cedes  sensation.  it  is  thus  local  sensation  precedes 

movement. 

3.  No  tonic  stage,  at  least  not     Tonic  stage   nearly  constantly  pre- 

marked.  sent. 

4.  Comparatively  rarely  goes  so     Loss  of  consciousness  is  a  constant 

far  as  general  loss  of  con-         feature,   though   it    may    be    only 
sciousness.  momentary. 

5.  After    a    fit,    paralysis,   or    at     Paralysis   after   a   fit  not  present,  a 

least  weakness,  is  a  marked  feeling  of  tiredness  in  general  the 

feature  in  the  locality  of  the         only  evidence  of  motor  distress, 
commencement. 

6.  No  sleepiness  after  a  fit.  Sleepiness  very  frequent  after  a  fit. 

B. — Other  Motor  Disturbances  of  Voluntary  Move- 
ments— 

Besides  Jacksonian  epilepsy,  the  following  involuntary  movements 
are  usually  assumed  to  be  due  to  damage  of  the  brain,  because  (i) 
they  are  usually  associated  with  mental  deterioration;  (2)  they 
cease  during  sleep  as  a  rule ;  (3)  they  are  more  complex  in  gross 
aspect  than  we  are  accustomed  to  see  in  pure  spinal  movements. 

Paralysis  agitans.  Coarse  rhythmical  movements,  usually  of  the  head 

and  hands,  more  marked  during  inaction ; 
often,  too,  these  are  of  the  hemi-  type,  another 
argument  for  a  brain  origin. 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  311 

1 

Chorea.  •  Coarse,  involuntary  imitations  of  purposive  move- 

ments, continuous  during"  waking  hours  ;  also 
often  of  hemi-  type. 

General  paralysis  of  Principally  of  lips  and  tongue  during  speech,  also 
insane.  seen    in   the    limbs ;     the   morbid  anatomy   of 

this  disease  is  known  to  be  a  fine  cortical 
sclerosis. 

Chronic  alcoholism  Coarse  tremor  of  hands  upon  attempted  fine 
or  mercurialism.  movements. 

Athetosis.  Peculiar    rolling    movement    of   affected    digits  ; 

frequently  post-hemiplegic,  and  then  indicates 
that  the  lesion  is  probably  near  the  cortex. 

C. — Symmetrically  used  Muscles — 

In  those  symmetrical  muscles  of  the  two  sides  of  the  trunk  and 
face  which  are  almost  never  used  independently  in  health,  e.g.  inter- 
costals,  eye  muscles,  etc.,  complete  paralysis  is  never  seen  from  a 
one-sided  central  lesion ;  the  explanation  of  this,  known  as  Broad- 
bent's  hypothesis,  is  that  such  muscles  are  stimulated  into  action 
with  nearly  equal  facility  from  either  hemisphere,  either  through  the 
corpus  callosum  or  through  mechanisms  in  the  mid-brain  (?  cere- 
bellum). 

ON  THE  SENSORY  SIDE 

Information  and  facts  are  much  less  definite  and  numerous  in 
considering  afferent  than  efferent  impulses.  When  once  the  sensory 
impulse  has  reached  the  medulla  on  its  centripetal  journey  we  know 
little  or  nothing  about  it  and  its  neuron  complexes,  or  series  of 
complexes,  till  it  reaches  the  posterior  third  of  the  posterior  limb  of 
the  internal  capsule.  It  is  clinical  observation  that  has  taught  us 
that  afferent  impulses  are  absolutely  necessary  for  the  co-ordinate 
and  harmonious  working  of  the  whole  body ;  but,  so  far  as  inco- 
ordination in  the  narrower  sense  of  mere  movement  is  concerned, 
we  have  only  one  fact  of  importance  to  guide  us,  viz.  that  if  inco- 
ordination be  due  to  spinal  or  peripheral  lesions,  as  in  tabes,  in  all 
probability  the  knee  jerk  will  be  absent,  if  it  be  due  to  intracranial 
lesions  the  knee  jerk  will  be  either  natural  or  exaggerated. 

HEMIANiESTHESIA 

Due  to  an  organic  cause  is  an  excessively  rare  phenomenon 
when  standing  alone  ;  when  with  hemiplegia  it  almost  conclusively 
proves  a  lesion  of  the  internal  capsule,  because  it  is  only  here  that 


312  DIFFERENTIAL  DIAGNOSIS  chap. 

the  sensory  fibres  are  sufficiently  close  together  and  to  the  motor 
ones  to  be  thus  affected  by  a  lesion  small  enough  to  not  cause  such 
an  interference  as  will  either  rapidly  prove  fatal  or  have  such  an 
effect  upon  consciousness  as  to  prevent  trustworthy  observations. 

N.B. — This  last  statement  should  be  carefully  borne  in  mind,  for 
it  is  the  clue  to  the  reason  why  many  bizarre  effects  in  cerebral 
troubles  have  not  been  noted ;  if  the  lesion  is  great  enough  to 
damage  tracts  widely  separated,  it  is  either  multiple  or  so  large  as  to 
cause  rapid  death. 

Hemianaesthesia  as  the  sole  evidence  of  disease  is  almost  in- 
variably due  to  functional  and  recoverable  causes  probably  affecting 
the  internal  capsule. 


ON  THE  MENTAL  SIDE 

If  there  be  no  pyrexia  or  other  evidence  of  local  disease  outside 
the  nervous  system,  then,  qua  localisation  from  mental  phenomena, 
all  we  can  say  is  that  the  disease  is  above  the  pons  and  crura,  and 
in  all  probability  is  in  the  cortex  of  the  cerebrum.  They  arise  in 
all  probability  from  a  loosening  of,  or  at  least  alteration  in,  the 
synapsial  connections  of  the  cortical  neurons.  Clinical  experience 
would  tend  to  suggest  that  the  frontal  lobes  have  more  to  do  with 
the  mind  than  any  other  part,  but  nothing  beyond  this  can  be  said. 
%  ^  ^  %  M-  % 

We  have  now  to  deal  with  the  differentiating  points,  and  especially 
to  note  them  as  regards  the  intracranial  portion  of  the  system. 

I  propose  to  discuss  the  matter,  so  far  as  necessary,  under  the 
following  headings : — 

1.  Traumatism. 

2.  Functional  troubles. 

3.  Ordinary  organic  lesions. 

I.  Traumatism 

Speaking  generally,  the  incidence  of  an  accident  of  gross  nature 
and  its  immediate  results  are  easy  enough  to  appreciate,  but  there 
are  a  few  cases  of  nerve  troubles  not  perhaps  usually  included  in 
the  term,  but  which,  I  think,  should  be  so  included,  for  they  are 
essentially  traumatic  in  constitution.  Chorea  after  fright,  neuritis 
or  so-called  occupation  neurosis,  i.e,  after  prolonged  special  use  of 
nerves,  and  the  results  of  shock,  are  illustrations  of  my  meaning. 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  313 

Probably  in  all  there  may  be  an  underlying  functional  or  structural 
weakness  of  the  nervous  system,  but  this  does  not  really  affect  my 
point. 

If  we  thus  widen  our  conception  of  traumatism,  we  have  the 
following  separate  groups  of  possible  results  : — 

{a)  Gross  laceration  or  bruising  of  tissue,  with  acute  inflamma- 
tion, followed  or  not  by  suppuration  and  abscess  forma- 
tion, of  all  of  which  the  traumatism,  with  entry  of  pyogenic 
germs,  is  at  once  an  obvious,  complete,  and  satisfactory 
diagnostic  explanation. 

(J?)  Tumour  of  malignant  or  simple  character,  where  again 
nothing  more  need  be  said,  for  the  tumour  is  either  a 
blood  clot,  or  it  remains  in  the  shape  of  a  cyst,  or  is  of 
a  heteroplastic  nature  —  there  are  too  many  cases  on 
record  of  the  last  incident  to  leave  any  room  for  discus- 
sion as  to  the  sequence  of  events.  (For  further  notes, 
vide  p.  323.) 

{c)  Sickness  or  degeneration  of  neuron  processes,  which  may 
end  in  recovery,  or  in  ultimate  death  and  sclerosis  of  the 
whole  neuron,  according  to  the  severity  of  the  changes 
started  in  it  and  the  general  recuperative  power  of  the 
animal  functions  of  the  whole  body. 

This  is,  I  think,  the  explanation  of  such  cases  as  those  mentioned 
above — shock,  chorea,  occupation  neurosis — and  possibly  others. 
I  believe  that  the  potential  (to  use  an  electric  analogy)  of  the 
stimuli  sent  through  the  neuron  processes  has  been  so  high,  or  the 
current  so  long  continued,  as  to  have  heated,  melted,  or  disturbed 
the  molecular  constitution  of  the  wires  or  connections,  with  resultant 
temporary  or  permanent  loss  of  conducting  power.  This  analogy 
must  not  be  driven  too  close  in  detail,  but  in  broad  outline  seems 
to  me  to  offer  the  best  explanation  of  such  cases.  However  this 
may  be,  the  relationship  of  external  cause  with  the  clinical  symptoms 
is  admitted  by  all.  Of  the  diagnosis  of  chorea  and  shock  little 
needs  to  be  said;  their  features  are  unmistakeable.  The  only 
problem  connected  with  them  is  whether  the  connections  or  wires 
of  the  nerve  mechanisms  can  be  repaired,  and  this  point  can  only 
be  proved  by  time.  Suffice  it  to  say,  that  repair  is  the  rule,  though 
this  may  be  not  quite  complete.  Of  the  identification  of  an  occu- 
pation neurosis  or  neuritis  one  can  only  emphasise  the  great  fact, 
from  which,  indeed,  they  derive  their  name,  viz.  that  the  pain  or 
spasm,  or  inco-ordination,  complained  of  by  the  patient  is  only  pro- 


314  DIFFERENTIAL  DIAGNOSIS  chap. 

duced  by  the  special  movements  peculiar  to  the  particular  occupa- 
tion (writing,  violin  playing,  etc.).  None  of  them  appear  when  the 
same  nerves  and  muscles  are  used  for  other  combinations.  This  is 
at  least  true  in  the  early  stages  of  the  malady,  but  recent  observa- 
tions tend  to  show  that  a  definite  neuritis  does  frequently  exist.  If 
and  when  this  is  so,  it  is  easily  explained  on  the  above  hypothesis. 
The  fact  that  these  neuroses  are  exhibited  only  in  the  performance 
of  one  special  combination  of  movements  is  a  strong  argument  in 
favour  of  a  primary  lesion  in  the  cortex,  where  combined  movements 
and  not  muscles  are  chiefly  represented  {vide  supra^  p.  257).  It  may 
also  be  mentioned  that  the  following,  amongst  others,  suggest  a 
cortical  seat  for  the  troubles  causing  chorea  and  shock : — 

{a)  That  they  are  practically  always  associated  with  some  altera- 
tion in  the  mental  or  psychological  conditions  of  the 
patient. 

ip)  That  they  very  frequently  exhibit  themselves  on  one  side  of 
the  body  only. 

{c)  That  the  trouble  is  exhibited  by  complex  combined  move- 
ments which  are  originated  in  the  cortex. 

2.  Functional  Troubles 

On  p.  275  will  be  found  a  definition  of  the  term  "functional," 
and  the  tables  and  remarks  throughout  this  section  may  be  used  to 
locate  the  weakened  neurons,  for  it  is  only  by  perverted  function 
as  exhibited  peripherally  that  we  can  locate  the  weakness.  Here  I 
wish  to  draw  attention  to  a  division  of  these  cases  into  {a)  those 
due  to  traumatism  as  defined  above,  and  (J?)  those  due  to  a  general 
constitutional  cause  resulting  in  a  loss  or  perversion  of  will  power. 
In  the  latter  group  of  cases,  constituting  the  hysteria  of  the  layman, 
or  the  "  cussedness  of  the  individual,"  I  believe  that  the  primary 
and  essential  lesion  resides  in  the  cortex  of  the  brain  (?  and  cere- 
bellum), and  consists  in  imperfections  of  the  synapses  of  the  inter- 
nuncial  neurons  with  one  another,  perhaps  associated  with  altered 
stability  of  the  molecular  constitution  of  the  neurons  themselves. 

3.  Ordinary  Organic  Lesions 

There  is  one  exceedingly  important  general  observation  to  be 
made  which  links  all  these  into  one.  It  is  this  :  We  must  never  for- 
get the  great  frequency  with  which  acute  vascular  lesions  are  found 
as  a  complication — very  frequently  forming  the  closing  episode — in 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  315 

the  more  chronic  troubles,  particularly  in  tumours  and  in  sclerosing 
lesions ;  so  that,  while  recognising  the  acute  condition,  we  must 
never  omit  to  inquire  very  carefully  for  evidence  of  a  possible  pre- 
existing chronic  trouble  {vide  also  pp.  272  and  278).  By  putting  the 
definite  question,  "  When  was  the  patient  last  quite  well  and  in  his 
normal  condition  ?  "  and  further,  by  inquiring  for  any  slighter  mani- 
festations of  ill-health  that  may  have  preceded  the  actual  attack 
for  which  our  assistance  is  required,  we  shall  not  only  get  evidence 
of  a  second  lesion  if  one  exists,  but  we  shall  also  gain  informa- 
tion that  may  be  of  the  greatest  service  in  deciding  between  the 
various  possible  causes  of  the  attack. 

We  may  now  proceed  to  an  analysis  of  the  lesions  themselves 
individually.     Those  which  I  propose  to  discuss  briefly  are : — 

Inflammation,  haemorrhage,  thrombosis,  and  embolism  (acute 

vascular  lesions). 
Idiopathic  afl'ections  of  neurons. 
Tumours. 

The  following  analysis,  with  the  appropriate  change  in  locality, 
wdll  frequently  apply  as  well  to  the  cord  and  nerves  as  to  the  brain. 

Broadly  speaking,  they  divide  themselves  clinically  into  two 
groups:  (i)  irritative,  (2)  destructive  lesions;  but  the  distinction, 
though  useful,  cannot  be  maintained  in  its  entirety.  For  in  the 
life  history  of  an  irritative  pathological  lesion  (physiological  stimuli 
apparently  have  no  such  limits)  there  is  to  be  noted,  first,  a  period 
of  excessive  functioning  in  the  affected  neurons  (pain,  parEesthesias, 
twitchings  or  contractions  of  muscles),  followed  by  a  period  in 
which  this  excess  becomes  less  and  less,  until  it  becomes  a  nega- 
tive quantity,  finally  function  is  completely  abolished  (ansesthesia 
and  paralysis),  in  which  stage  the  symptoms  are  those  of  a  para- 
lysing lesion — another  reason  for  carefully  ascertaining  the  whole 
history  of  the  case.  Then,  again,  the  distinction  of  irritation  v. 
destruction  w411  depend  in  some  cases  on  the  situation  of  the  lesion, 
meninges,  or  perineurium  v.  bulk  of  brain,  cord  or  nerve  strands. 
Inflammation,  hsemorrhage,  and  frequently  also  tumour,  will  at  all 
times  offer  good  examples  of  this  variability  with  locality. 

Acute  Vascular  Lesions 
Acute  Iiiflamf nation. 

(For  diagnosis  of  Peripheral  Neuritis,  vide  pp.  281  et  seq. 
and  pp.  2  9  2  (?/  seq. ) 

As  it  attacks  the  central  nervous  system  it  occurs  in  two  well- 


3i6  DIFFERENTIAL  DIAGNOSIS  chap. 

marked  forms,   i.e.   meningitis  and  encephalitis  or   myelitis,   which 
require  separate  notice. 

Of  the  Membranes,  Meningitis. — Here,  as  anywhere  else,  acute 
inflammation  excites  general  symptoms,  viz.  pyrexia,  with  malaise 
and  discomfort.  The  special  points  leading  us  to  locate  it  in  the 
nervous  system  are  the  concentration  of  the  pain  in  the  back,  or 
in  the  head,  with  rapid  onset  of  grave  symptoms  of  impHcation  of 
nerve  matter,  or  of  pressure  on  it  (affections  of  cranial  nerves — 
squint,  facial  paralysis,  etc. — vomiting,  optic  neuritis,  unconscious- 
ness, jumping  of  muscles,  feebleness  of  gait,  or  paraplegia,  etc.).  In 
its  irritative  stage  it  may  require  separation  from  meningeal  haemor- 
rhage or  tumour.  From  the  former,  its  slower  onset  and  the  pyrexia 
will  be  sufficient ;  from  the  latter,  the  pyrexia  again  and  its  more 
rapid  (a  day  or  two  at  most  v.  a  week  or  two  at  least)  onset 
should  usually  leave  no  doubt. 

In  its  paralytic  stages  it  becomes  essentially  a  cortical  myeHtis 
or  cerebritis,  and  only  the  history  shows  that  such  began  as  a 
meningitis. 

Of  the  Cord. — The  rapid  onset  of  a  complete  paraplegia  could 
only  arouse  suspicion  of  blocking  or  rupture  of  a  vessel  apart  from 
a  myelitis.  Thrombosis  or  plugging  of  spinal  vessels  is  so  rare  as 
to  be  a  mere  curiosity,  but  both  this  and  haemorrhage  will  be  in 
their  earlier  stages  sufficiently  separated  from  myelitis  by  their 
absolutely  sudden  onset,  and  by  the  absence  of  pyrexia.  In  their 
later  stages  all  three  lesions  would  be  identical. 

Of  the  Brain. — A  primary  cortical  acute  cerebritis  is  extra- 
ordinarily rare.  If  it  occurred  it  would  precisely  resemble  an  acute 
meningitis,  except  that  there  would  be  a  more  rapid  onset  of  para- 
lytic phenomena,  especially  in  the  limbs  (vertical  meningitis),  or  in 
cranial  nerves  (basal  meningitis). 

Acute  primary  medullary  cerebritis,  i.e.  in  the  mass  of  the 
brain,  is  practically  only  known  in  the  shape  of  an  abscess,  and 
then  the  principal  point  is  to  separate  it  from  a  tumour.  Their 
likenesses  and  differences  may  be  summed  up  thus.  Both  will  be 
equally  likely  to  have — 

1.  Vomiting. 

2.  Optic  neuritis. 

3.  Headache  (intense). 

4.  Localising  paralytic  phenomena,  or  irritative. 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  317 

On  the  other  hand,  they  will  probably  differ  as  follows : — 


Abscess. 

1.  A  history   of   some    peripheral 

suppuration — ear,  nose,  and 
other  discharges — which  has 
possibly  ceased  just  previous 
to  symptoms  of  cerebral 
trouble. 

2.  Symptoms   may  quite   possibly 

come  on  with  great  rapidity, 
and  rapidly  get  more  serious. 

3.  Temperature  a  little  raised,  or 

more  probably  subnormal. 

4.  Irritative  phenomena  rare,  para- 

lytic phenomena  at  once  or 
rapidly  coming  on. 


Tumour  of  other  Nature. 
Probably  no  such  history,  but  there 
may  be  a  tumour  elsewhere  sug- 
gestive of  a  primary  growth,  to 
which  the  cerebral  one  may  be 
secondary. 

Symptoms  rarely  increase  with 
great  rapidity  unless  it  be  with 
instantaneous  exacerbation,  indi- 
cating haemorrhage  into  tumour. 

Temperature  either  quite  normal, 
or  with  greater  and  more  irregu- 
lar ranges  than  in  abscess. 

Irritative  phenomena  commoner, 
and  lasting  longer  than  in  ab- 
scess. 


Hcemorrhage,  Thrombosis^  and  Embolism — 

The  one  essential  feature  common  to  all  these,  and  the  one  by 
which  they  are  as  a  group  separated  from  all  other  lesions,  is  the 
instantaneous  rapidity  with  which  their  symptoms  commence,  and 
speedily  reach  an  acme.  The  two  latter  never  as  a  simple  diagnos- 
able  lesion  occur  in  the  meninges,  but  the  former  frequently  does 
so,  and  it  is  of  some  importance  to  distinguish  this  situation  of  it 
if  we  can  : — 


Meningeal  Haemorrhage. 

1.  Commoner  when  idiopathic  in 

young  subjects. 

2.  Very  rare,  except  as  the  result 

of  traumatism,  forceps  at  birth, 
e.g.^  or  blows  on  the  head  or 
back. 

3.  Commencement    of    symptoms 

sudden,  but  generally  some 
minutes  or  even  hours  before 
they  reach  their  acme,  ix, 
more  ingravescent. 


Haemorrhage  into  Bulk  of  Brain  or 
Cord. 

Commoner  in  older  subjects  when 
without  exciting  cause. 

Very  common,  without  any  history 
of  traumatism  :  is  equally  rare 
as  the  result  of  violence,  unless 
this  be  very  severe. 

Instantaneous  commencement,  and 
acme  reached  almost  with  the 
same  rapidity ;  gradual  ingra- 
vescence  is  much  rarer,  though 
well  recognised  as  occasionally 
occurring. 


3i8  DIFFERENTIAL  DIAGNOSIS  chap. 

In  this  point  of  contrast  it  is  obvious  that  exceptions  must 
occur  in  connection  with  the  size  of  the  vessel  which  has  ruptured, 
e.g.  the  middle  meningeal  or  the  basilar,  on  the  one  hand,  the 
symptoms  of  which  will  be  indistinguishable  almost  from  intra- 
cerebral haemorrhage ;  or,  on  the  other  hand,  a  very  small  branch 
of  an  intracerebral  artery,  the  symptoms  of  which  may  be  very 
slowly  ingravescent.  Concussion,  or  brain  bruising,  is  another 
exception,  but  its  onset  is  always  traumatic  and  sudden. 

, ,     .         ,  TT  I-  Haemorrhage  into  Bulk  of  Brain  or 

Meningeal  Hsemorrnage,  r    d 

4.  The      symptoms      usually     go     The  symptoms  cannot  be  said  to 

through    an    irritative    stage,  have  any  irritative  stage ;   they 

which    is     easily    observable  are  destructive  from  the  earliest 

and  may  be  prolonged  (pain  time  of  observation, 
or  convulsive  movements). 

5.  The    subsequent    course    may  Recovery  never  complete,  and  the 

show       complete       recovery,         focal  lesion  will  always  be  found 
though  possibly  an   irritative         to  be  a  destructive  one. 
focus  may  be  left  behind. 

In  discussing  the  separation  of  the  three  troubles  as  they  occur 
in  the  bulk  of  the  brain  or  cord,  it  must  be  admitted  once  for  all 
that  a  positively  certain  diagnosis  (ante-mortem)  is  impossible,  but 
a  more  or  less  intelligent  and  probably  correct  guess  may  be 
hazarded  by  attention  to  the  following  points : — 

1.  That  in  the  spinal  cord  the  communication  of  the  vessels  is 
so  free  and  easy  that  embolism  and  thrombosis  are  of  the  very 
rarest  occurrence  of  sufficient  extent  to  cause  a  definite  paraplegia. 

2.  Age. — Though  the  cause  leading  to  embolus  direct  from  the 
heart  (acute  endocarditis)  is  commoner  in  young  subjects,  and  also 
syphilis  and  tubercle  as  active  causes  of  local  thrombosis,  yet  none 
of  them  cease  absolutely  as  age  advances.  Moreover,  atheroma, 
another  principal  cause  of  thrombosis  or  embolism  (from  debris),  is 
distinctly  an  affection  of  advancing  years.  Hence  age,  per  se,  gives 
us  no  very  strong  and  leading  guidance ;  nevertheless  it  must  be 
stated  that,  ceteris  paribus  (which  they  seldom  are),  the  older  the 
patient  the  more  do  our  thoughts  go  in  the  direction  of  haemorrhage., 

3.  Marked  premonitory  symptoms  of  slight  attacks  are  likely  to 
make  us  think  of  thrombosis,  especially  if  syphihs  is  present,  or 
tubercle  a  probability.  The  reason  for  this  is  that  preliminary 
small   haemorrhages    are  rare,   and    so   also,   I  believe,   are   small 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  319 

emboli,  while  as  an  artery  gets  gradually  obliterated  we  should 
expect  premonitory  evidences  of  disturbed  nutrition  in  areas  which 
are  ultimately  going  to  die. 

4.  State  of  Consciousness. — If  we  bear  in  mind  that  haemorrhage 
forces  asunder  (by  a  pressure  increasing  as  the  cube  of  the  radius 
of  its  bulk)  the  fibres  of  the  brain,  and  adds  materially  to  the  bulk 
of  the  intracranial  contents  by  blood  which  should  be  escaping  by 
the  veins,  thus  increasing  the  intracranial  pressure ;  if,  too,  we 
bear  in  mind  that  loss  of  consciousness  (under  the  circumstances 
we  are  now  considering)  is  probably  due  to  increase  of  pressure  on 
the  cerebral  cortex,  or  to  violent  impressions  upon  it,  and  then 
consider  that  the  plugging  of  a  vessel  from  any  cause  has  no  such 
tendency,  w^e  shall  see  the  probable  explanation  of  Trousseau's 
statement  (which  is,  I  believe,  still  in  accord  with  clinical  experi- 
ence), that  "  Whenever  hemiplegia,  complete  and  absolute  "  (there- 
fore due  to  a  rather  serious  lesion),  "  occurs  suddenly "  (therefore 
due  to  vascular  lesion)  "  without  the  loss  of  consciousness  "  (there- 
fore without  much  pressure),  "it  is  more  likely  to  be  due  to 
softening  (plugging)  than  to  haemorrhage." 

5.  State  of  Heart. — If  in  a  young  subject,  otherwise  in  usual 
health,  we  hear  cardiac  bruits,  they  will  be,  ipso  facto^  suggestive  of 
embolus,  provided  the  heart  is  acting  fairly  quietly  and  regularly, 
and  the  more  suggestive  the  more  recently  the  bruits  are  known  to 
have  developed.  If,  on  the  other  hand,  we  find  a  powerful  heart 
acting  violently  with  or  without  bruits,  we  suspect  that  this  power 
has  ruptured  a  weakened  vessel,  especially  if  the  attack  (hemiplegia) 
came  on  during  exertion  or  excitement  (one  of  the  great  dangers  of 
alcohol  when  taken  by  a  person  with  damaged  vessels).  Finally, 
if  the  heart  beat  is  very  feeble,  as  after  a  severe  illness  of  any  sort, 
and  during  convalescence,  the  feebleness  of  the  circulation  is  sug- 
gestive of  thrombosis,  either  locally  at  a  distance  from  the  heart, 
i.e.  in  the  brain,  or  of  clotting  in  the  irregular  chambers  of  the 
heart  and  propulsion  of  an  embolus  thence. 

6.  Te7?iperature. — Haemorrhage  always  causes  a  fall  in  the  tem- 
perature, which  may  continue  till  death  or  be  replaced  by  irregular 
pyrexia.  Plugging  of  a  vessel  rarely  causes  much  fall,  and,  if  it 
does  so,  the  temperature  soon  rises  to  normal,  and  continues  there 
with  very  slight  or  no  variation,  so  that  the  greater  the  excursions 
of  the  thermometer  the  more  do  we  think  of  haemorrhage. 

If  these  various  indications  are  properly  balanced,  a  correct  con- 
clusion will  more  often  than  not  be  arrived  at,  though  many  mis- 
taken diagnoses  will  undoubtedly  occur. 


320  DIFFERENTIAL  DIAGNOSIS  chap. 

It  must  not  be  overlooked  on  the  post-mortem  table  that  a  fatal 
plugging  may  yield  no  very  obvious  signs,  because  the  softening 
which  we  look  for  as  proof  of  plugging  is  a  phenomenon  which 
only  commences  some  little  time  after  the  circulation  through  the 
part  has  ceased.  It  may  not  be  out  of  place,  too,  to  mention  that, 
whether  the  softening  be  white,  red,  or  yellow,  it  is  merely  an  acci- 
dental result  of  (i)  the  age  of  the  process;  (2)  the  amount  of 
blood  or  other  pigment,  or  their  derivatives,  left  in  the  area  by 
circumstances  of  absorption ;  it  has  no  special  significance  suggestive 
of  a  difference  in  the  pathology  of  the  lesion. 

Idiopathic  Affections  of  Neurons 

Though  in  no  sense  of  the  word  idiopathic,  there  is  no  other 
connection  in  which  the  effects  of  hgemorrhage  or  plugging  can  be 
more  appropriately  placed ;  consequently,  we  must  tabulate  the  above 
heading  as  follows  : — 

1.  Secondary  to  their  death  by  gross  violence,  whether  from 

haemorrhage  or  plugging. 

2.  Idiopathic — 

{a)  Acute,  usually  termed  acute  inflammation. 
lb)  Chronic,  usually  termed  primary  sclerosis. 

I.  Of  the  secondary  form  but  little  need  be  said;  it  undoubt- 
edly occurs  as  a  sclerosis  of  a  tract,  or  track,  after  haemorrhage  from 
or  plugging  of  a  vessel  has  destroyed  the  nutritive  mechanism,  but 
it  adds  litde  or  nothing  to  the  clinical  picture  already  portrayed. 
The  paralysis,  or  anaesthesia,  or  both,  and  the  exaggerated  reflexes 
appear  rapidly  as  the  result  of  the  death  of  the  neuron  ;  the  subse- 
quent sclerosis  merely  fixes  these  in  rigid  features,  and  adds  certain 
confirmation  to  a  previous  diagnosis  of  organic  mischief. 

2  {a).  The  acute  primary  affection  has  its  chief,  if  not  its  only, 
seat  in  the  neuron  cells  of  the  motor  areas  (nuclei  of  nerves),  at 
any  rate  this  locaUsation  property  is  so  constant  that  cUnically  it 
affords  one  of  the  strongest  points  of  evidence  in  favour  of  the 
particular  pathological  lesion,  i.e.  of  primary  acute  inflammation  or 
degeneration.  We  find  it  most  commonly  in  the  spinal  cord  as 
acute  anterior  poliomyelitis,  the  diagnostic  points  of  which  have 
already  been  considered  on  p.  292,  but  it  must  not  be  forgotten 
that  the  nuclei  of  origin  of  the  motor  cranial  nerves  are  absolutely 
analogous  in  function,  if  not  even  serially  homologous  in  structure, 
to  those  of  the  anterior  cornua,  and  are  therefore  found  to  be 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  321 

liable  to  the  same  affections ;  hence  an  acute  bulbar  paralysis  or  an 
acute  affection  of  an  isolated  cranial  nerve  nucleus  may  and  does 
occur.  Its  history  will  be  one  of  acute  {i.e.  complete  within  twenty- 
four  hours)  onset,  accompanied  probably  by  a  slight  pyrexia ;  the 
latter  may  be  so  slight  or  fugitive  as  to  escape  observation,  and 
hence  the  disease  may  resemble  at  its  onset  a  small  haemorrhage  or 
softening.  The  differences  in  such  an  acute  case  will  principally 
consist  in  the  following  : — 

{a)  Although  it  is  possible,  yet  as  a  matter  of  clinical  experience, 
the  onset  rarely  is  so  instantaneous  as  in  hemorrhage. 

(B)  There  will  be  at  any  rate  in  a  few  hours  after  onset  an 
almost  complete  absence  of  any  sensory  phenomena. 

ic)  In  the  bulb  if  the  cause  of  the  trouble  were  a  haemorrhage 
or  softening,  it  is  almost  inevitable  but  that  some  limb 
paralysis  or  anaesthesia  should  be  found,  for  the  vessels 
supplying  these  motor  nuclei  do  not  confine  their  nutri- 
tive supply  to  these  alone;  and  we  have  already  noted 
the  peculiar  precision  with  which  this  lesion  does  pick 
out  the  motor  cells  only. 

In  the  identity  of  its  results  upon  the  peripheral  nerve  and 
the  muscles  supplied  by  it  (degeneration  and  atrophy),  it  has  to  be 
separated  from  purely  peripheral  lesions  ;  difficulties  arise  here  more 
in  theory  than  in  practice ;  nuclear  lesions  are  seldom  quite  com- 
plete {e.g.  of  third,  seventh,  sixth,  twelfth,  etc.),  while  peripheral  ones 
are  specially  prone  to  be  so,  particularly  if  the  nerve  {e.g.  the  seventh) 
passes  through  a  bony  canal.  Again,  if  the  peripheral  lesion  be 
only  partial,  its  causes  (meningitis,  gummata,  tumours,  etc.)  are 
associated  with  general  symptoms  or  local  phenomena  (swelling, 
pain,  etc.)  of  such  obtrusiveness  as  to  leave  little  room  for  doubt  if 
the  case  be  seen  in  an  early  stage.  In  later  stages  diagnosis  will 
be  impossible  without  the  history  to  guide  us. 

2  {b).  In  the  chronic  form  of  primary  sclerosis  of  tracts,  of 
which  the  following  are  the  chief  types  : — 

Tabes  dorsalis  ^ 

Lateral  sclerosis  >  of  the  cord  ; 

Progressive  muscular  atrophy  J 

Disseminated  sclerosis  of  cord  and  brain  ; 

Chronic  bulbar  paralysis  of  bulb  ; 

?  Paralysis  agitans   1      r  ^      ■ 
:i  o     -1    ^  r  of  bram  cortex: 

-  ?  benile  tremors      J 

Y 


32  2  DIFFERENTIAL  DIAGNOSIS  chap. 

the  principal  feature  which  separates  them  at  once  from  every  other 
lesion  —  except  a  very  slowly  growing  tumour  —  is  the  extreme 
chronicity  of  the  process,  so  that  symptoms  are  slowly  developing 
for  many  months  at  least,  and  often  even  for  years.  The  extreme 
precision  with  which  this  affection,  i.e.  primary  sclerosis,  picks  out 
certain  tracks  and  strands  (except  disseminated),  is  also  as  marked 
a  feature  as  in  the  acute  form,  so  that,  when  combined  with  chroni- 
city, it  leaves  little  room  for  doubt,  at  any  rate  in  advanced  cases. 
The  individual  diseases  have  already  received  {supra)  sufficient 
attention ;  it  remains  here  only  to  remark  on  the  likeness  of  the 
process  to  functional  disorders.  If  we  consider  the  minute  patho- 
logical processes  underlying  the  gross  sclerosis  (the  final  stage),  it 
is  easy  to  see  that  in  the  early  stages  of  the  trouble  we  are  now  con- 
sidering, it  is  probable  that  a  time  will  occur  in  which  only  function 
will  have  suffered,  and  consequently  this  will  be  a  stage  in  which 
the  greatest  difficulties  may  occur  in  separation ;  in  fact,  there  may 
be,  and  even  probably  must  be,  identity  of  symptoms  with  a  differ- 
ence only  in  future  progress.  Attention  may  be  drawn  to  p.  297, 
where  the  differences  between  disseminated  sclerosis  and  functional 
troubles  are  discussed.  Besides  what  is  there  recorded  there  is  only 
the  general  consideration  of  the  element  of  time  ;  this,  in  the 
beginning  of  a  simple  functional  trouble,  which  is  not  going  to 
proceed  to  sclerosis,  is  likely  to  show  confusion  in  many  systems, 
as  opposed  to  stress  on  one  system  in  a  case  that  is  going  to  end 
in  sclerosis  ;  and  then,  again,  later  will  show  a  stationary  or  im- 
proving condition  in  the  former  versus  a  downhill  course  if  the 
fundamental  meaning  of  the  symptoms  is  the  starting  of  a  pro- 
gressive process  of  decay  and  degeneration. 

Tumours  of  Brain  (and  of  Cord) 

By  their  comparative  chronicity  or  comparative  acuteness, 
according  to  the  point  of  view  from  which  we  regard  them,  these 
troubles  separate  themselves  almost  conclusively  from  vascular  and 
acute  inflammatory  lesions  on  the  one  hand,  and,  on  the  other,  from 
chronic  idiopathic  scleroses.  From  the  latter,  too,  they  are  also 
separated  by  the  fact  that  they  are  very  indiscriminate  in  the 
pressure  they  exert :  they  spare  nothing  that  comes  within  their 
sphere  of  influence  (hence  the  predominance  in  the  cord  of  root 
symptoms).  As  they  affect  the  cord  they  will  receive  no  further 
notice,  but  from  their  importance  in  the  recent  advances  of  cerebral 
pathology  and  treatment  they  must  be  discussed  a  little  more  fully 
as  they  affect  intracranial  structures. 


VIII  DISEASES  OF  THE  NERVOUS  SYSTEM  323 

It  Is  common  knowledge  that  the  tripod  on  which  their  diagnosis 
mainly  rests  has  for  its  three  legs : — 

Headache. 
Vomiting. 
Optic  neuritis. 

To  these  are  frequently  enough  added  some  specific  features 
indicating  its  locality,  and  occasionally  its  precise  nature.  For  the 
former,  vide  Jacksonian  Epilepsy  and  the  Cranial  Nerves;  of  the  latter 
it  is  only  necessary  to  mention  a  definite  history  of  syphilis,  tubercle 
in  the  choroid  or  elsewhere,  and  a  primary  focus  in  some  organ  of 
sarcoma  or  carcinoma. 

Now,  any  one  of  these  three  legs  may  be  permanently  knocked 
away  and  yet  the  diagnosis  stand,  while  even  two  may  be  removed  for 
some  time  without  a  complete  overthrow  of  the  diagnostic  super- 
structure;  but  if  all  three  be  gone  it  is  only  in  the  rarest  of  instances, 
and  more  by  inspiration  than  logic,  that  we  should  venture  to  assert 
that  a  cerebral  tumour  was  present  because  of  some  incidental 
localising  suggestions. 

Headache. — Pain  in  the  head,  even  severe,  is  such  a  common 
complaint  that  not  much  stress  can  be  laid  on  this  symptom  until 
the  other  common  sources  of  it  have  been  excluded.  We  may 
say  that  unless  at  least  one  of  the  other  two  guiding  indications 
were  present  it  would  hardly  arouse  suspicion  of  a  cerebral  neoplasm 
(not  but  that  the  neoplasm  may  be  there,  without  our  suspecting  it), 
except  it  possessed  in  rather  a  marked  degree  some  or  all  of  the 
following  features  :  (i)  very  persistent  and  resistant  to  remedies,  and 
possibly  paroxysmal;  (2)  so  severe  as  to  keep  the  patient  awake  at 
night ;  this  should  be  made  a  very  strong  point,  as  patients  vary 
very    much    in  their  estimation    of    the  intensity  of  a  headache ; 

(3)  located  in  one,  and  that  perhaps  an  unusual  part  of  the  head ; 

(4)  often  associated  with  acute  additional  pain  or  tenderness  on 
percussing  the  head  in  that  region  (this  is  commoner  in  superficial 
tumours,  and  when  definitely  present  is  a  valuable  localising  sign). 

Vo??iiting. — If  of  cerebral  origin  {vide  pp.  158  and  159)  is  usually 
stated  to  be  unassociated  wdth  much,  or  any,  nausea  ;  totally  inde- 
pendent of  food  (often  attempted  with  an  empty  stomach),  and  of 
a  peculiarly  forcible  (pumping)  character ;  certainly  none  of  these 
features  is  absolutely  constant,  even  in  the  certain  presence  of  a 
tumour,  but  we  may  safely  say  that  w^hen  a  patient  makes  special 
comiplaint  of  vomiting  as  the  chief  symptom,  and  no  definite  gastric 
or  alimentary  trouble  can  be  found  to  account  for  it,  it  is  imperative 


24 


DIFFERENTIAL  DIAGNOSIS 


CHAP. 


upon  us  to  examine  the  fundi  oculorum  and  inquire  more  particularly 
about  the  headache.  The  diseases  likely  to  cause  such  vomiting 
of  remote  or  obscure  origin  are  tabes  dorsalis  and  Addison's  disease, 
neither  of  which  should  offer  any  difficulties  in  exclusion,  at  least 
from  the  possible  occurrence  of  a  tumour. 

Optic  Neuritis. — Inasmuch  as  a  definite  optic  neuritis  occurring  as 
a  totally  independent  disease,  apart  from  any  discoverable  causation, 
is  the  very  rarest  of  phenomena,  if  not  absolutely  unknown,  it 
necessarily  follows  that  if  we  can  establish  its  certain  presence, 
and  if  we  can  exclude  other  causes,  we  have  almost  proved  to  a 
demonstration  the  presence  of  gross  intracranial  mischief  of  but  few 
categories. 

As  regards  its  recognition  it  can?iot  be  too  strongly  insisted  upon,  no? 
too  often  repeated^  that  severe  optic  neuritis  and  other  pathological  changes 
in  the  fundus  may  be  present  without  the  slightest  volujitary  co7nplaint  on 
the  part  of  the  patieitt  of  subjective  disturbances  of  vision^  nay  more^  he 
may  deny  such  even  when  the  direct  question  is  put  to  him,  so  that  the 
ophthalmoscope  is  absolutely  necessary  for  diagnosis. 

The  following  is  a  tolerably  complete  list  of  causes  of  the 
changes  found  in  the  fundus,  with  the  main  characters  of  separa- 
tion : — 


Gout,    cirrhotic   kid- 
neys, albuminuria. 


Specific    fevers,    ty- 
phoid, e.g. 

Leucocythsemia  and 
purpura. 


Embolism  of  central 
artery. 

Anasmia. 


Haemorrhages,  or  white  atrophic  spots,  the  chief 
feature  in  the  fundus  ;  the  examination  of  the 
urine,  and  other  evidences  of  vascular  degenera- 
tion, leave  no  room  for  mistakes. 

The  pyrexia,  the  rash,  and  general  symptoms  too 
well  marked ;  the  neuritis  itself  may  be  indis- 
tinguishable. 

Again  hemorrhages  are  the  prominent  feature  in 
the  fundus  ;  examination  of  blood  and  en- 
larged spleen  in  the  one  case,  and  haemor- 
rhages in  the  skin  in  the  other,  are  sufficient  to 
prevent  mistakes. 

Changes  are  in  the  yellow  spot,  not  In  the  disc, 
except  as  atrophy ;  arteries  and  veins  small 
instead  of  large.  Loss  of  sight  probably  com- 
plete in  the  eye  affected. 

Optic  neuritis  rare,  except  in  cases  of  very  marked 
pallor ;  examination  of  blood  gives  certain 
information.  I  have  known  even  Dr.  Jackson 
deceived  in  such  a  case,  however,  and  diagnose 
tumour  from  the  headache  and  optic  neuritis 
when  they  were  dependent  upon  simple  anaemia. 


VIII 


DISEASES  OF  THE  NERVOUS  SYSTEM 


325 


Lead  poisoning. 


Errors  of  refraction. 


Tubercle. 


In  tumour  of  ordin- 
ary character,  or 
syphilitic  or  tu- 
bercular, and  in 
abscess  or  men- 
ingitis of  any 
causation. 


It  is  very  rare  that  optic  neuritis  is  the  only  sign 
of  plumbism  in  a  doubtful  case  ;  wrist  drop  or 
colic,  or  blue  line,  nearly  sure  to  be  present ; 
occupation  or  opportunities  for  absorption 
important. 

This  is  rather  a  pitfall  in  estimating  the  presence 
of  a  neuritis  than  a  definite  cause  of  that  con- 
dition. They  must  be  carefully  excluded  as 
the  possible  causes  of  visible  fundal  pecuharities 
before  other  ones  are  sought ;  and  the  results 
of  their  correction  noted. 

Visible  as  small  nodules  in  the  choroid  ;  their 
presence  is  absolutely  conclusive  as  to  the 
nature  of  a  tumour  or  a  meningitis  if  previously 
doubtful,  but  they  are  only  rarely  present  even 
when  tubercle  is  the  cause  we  are  seeking  for 
certain  symptoms. 

The  optic  neuritis  when  present  has  usually  no 
distinctive  characters  peculiar  to  each  (?  tubercle 
above),  but  is  very  frequently  present  with  any 
of  them  as  very  strong  evidence  of  a  gross 
diagnosis. 


Such  are  the  principal  means  we  have  for  a  pathological  diag- 
nosis in  general  terms.  We  have  already  considered  the  separation 
of  meningitis  and  also  of  abscess.  The  question  of  the  space  of 
time  during  which  a  lesion  is  developing  its  features  has  already 
been  repeatedly  alluded  to,  and  so  also  have  those  features  which 
assist  us  in  forming  an  opinion  as  to  the  precise  locality  of  a 
disturbing  factor.  The  question  cannot  be  pursued  farther  with- 
out going  into  very  special  discussion  unsuitable  for  the  present 
work. 


CHAPTER   IX 

URGENCY   CASES 

Under  this  heading  I  propose  to  discuss  the  diagnosis  of  a  very 
mixed  group  of  cases  with  which  the  daily  press  has  from  time  to 
time  made  and  kept  us  famihar  under  the  attractive  (?)  title  of 
"  Drunk  or  Dying,"  in  allusion  to  the  fact  that  so  many  of  them, 
while  ending  fatally,  have  a  very  close  resemblance  to  the  varied 
phases  of  alcoholism  in  its  numerous  stages. 

It  is  for  lack  of  some  definite  principles  in  diagnosis  (and  treat- 
ment) that  so  many  mistakes  have  occurred,  mistakes  from  which 
no  extrication  is  possible,  and  through  which  more  than  one  medical 
reputation  has  foundered,  and  public  institutions  have  had  much 
undeserved  censure  cast  upon  them. 

We  may  define  the  group  to  which  I  refer  as  "  Cases  in  which 
we  are  called  upon — usually  in  a  great  hurry — to  examine  and  treat 
a  patient  in  whom  sudden  and  apparently  severe  illness  has  super- 
vened, and  whom  we  have  not  been  previously  attending,  or  with 
whose  previous  history  we  are  at  the  time  unacquainted."  This 
last  condition  is  put  in  to  temporarily  exclude  cases  of  illness 
which  are  known  to  be  complicated  with  sudden  storms,  though 
the  following  analysis  will  show  that  such  are  not  usually  present. 

We  will  commence  with  a  bare  enumeration  of  the  lesions  which 
are  liable  to  take  place  suddenly,  or,  perhaps  more  appropriately  to 
our  subject,  are  liable  to  cause  sudden  symptoms  in  persons  who  are 
apparently  in  perfect  health,  or  at  least  are  able  to  go  about  the 
public  thoroughfares  unattended.  They  divide  themselves  fairly 
naturally  into  groups  as  follows  : — 

I.  Haemorrhage. 
II.  Vascular  lesions  other  than  haemorrhage. 


CHAP.  IX  URGENCY  CASES  327 

III.  Traumatism. 

IV.  Sudden  death. 

V.   Lesions  and  conditions  of  the  nervous  system. 
VI.    Poisoning. 

This  is  a  fairly  complete  list  of  "  urgency  cases."  It  may  seem 
a  very  formidable  one  to  carry  in  mind,  but  in  practice  it  is  not  so, 
for  many  cases  are  self  obvious  from  the  first,  and  early  treatment 
can  proceed  on  but  very  few  lines. 

Group  I. HEMORRHAGE 

{a)  Through  breach  of  skin.  e.g.   Traumatism,  varicose  veins,  etc. 

{b)  Appearing  externally  e.g.  Hsematemesis,  hjemoptysis,  epis- 
through  rupture  of  vessel  taxis,    or    haemorrhage     from 

internally.  rectum. 

{c)    Concealed  haemorrhage.  e.g.   Rupture  of  aneurysm,  or  of  tubal 

gestation,  or  of  a  vascular 
organ,  especially  spleen  ; 
heemorrhage  into  stomach 
without  vomiting,  or  into  in- 
testine without  appearing  in  a 
stool.  (Cerebral  haemorrhage 
is  not  included  in  this  group, 
as  it  is  brain  laceration  and 
compression  that  cause  its 
symptoms.) 

From  the  point  of  view  of  a  provisional  or  preliminary  diagnosis 
guiding  U3  to  first  or  immediate  treatment,  this  group  stands  almost 
by  itself,  and  may  at  once  be  dismissed  rather  summarily.  Sub- 
divisions {a)  and  {h)  are  at  once  obvious  by  the  blood  round  the 
patient  (if  the  body  has  been  removed  or  the  blood  cleaned  up 
there  will  obviously  be  some  history  of  such  having  been  done). 
Group  {c)  offers  a  little  more  difficulty,  but  here  it  is  fair  to  assume 
that  if  the  haemorrhage  is  sufficiently  severe  to  necessitate  the 
attendance  of  a  medical  man,  it  will  be  sufficient  to  cause  very 
marked  blanching  of  the  face,  and  faintness,  with  the  small  pulse, 
weak  or  husky  voice,  and  sighing  respiration  characteristic  of  a 
severe  loss  of  blood.  A  ruptured  aneurysm,  spleen,  or  ectopic 
gestation  is,  besides  the  faintness  and  blanching,  also  very  likely 
to  cause  severe  local  pain,  directing  attention  to  the  region  in 
question. 


328  DIFFERENTIAL  DIAGNOSIS  chap. 

Group  II. — Vascular  Lesions  other  than  Haemorrhage 

e.g.  Simple  fainting,  angina  pectoris.  (Blocking  of  blood-vessels 
is  excluded  here,  as  the  symptoms  entirely  depend  on  the 
locality  of  the  block.) 

A  diagnosis  of  either  of  these  conditions  is  usually,  like  that  of 
haemorrhage,  fairly  easy.  Either  of  them  may  have  ended  in  rapid 
death  (a  subject  of  special  grouping,  vide  below),  in  which  case 
let  me  strongly  urge  that  no  diagnosis  should  be  given  without  a 
complete  autopsy.  Fainting,  if  not  due  to  actual  haemorrhage  {vide 
above),  is  commonly  very  transient ;  if  prolonged,  it  can  only  be 
diagnosed  as  a  simple  lesion  by  exclusion  of  the  indications  of 
Groups  V.  and  VI.  {vide  pp.  331,  ZZ'^\ 

Angina,  if  of  any  severity  (and  it  is  only  then  that  it  becomes 
an  "  urgency  case  "),  will  be  recognised  by  the  position  of  the  pain 
in  the  chest,  and  the  fixed  attitude  of  the  patient  from  the  fear  of 
death  on  movement. 

Group  III. — Traumatism 
The  only  conditions  that  can  arise  from  traumatism  are — 

(i)  The  actual  injury  to  limbs  or  viscera. 

(2)  Shock  to  the  nervous  system,  which  may  be    sufficiently 

severe  to  cause  death. 

(3)  Unconsciousness,  from — 

{a)  Sh^ck,  pure  and  simple, 

{b)  The  nature  or  locality  of  the  injury,  e.g.  of  brain. 

(4)  Death. 

If  the  victim  is  conscious,  and  thus  a  history  obtainable,  no 
difficulties  in  forming  a  preliminary  diagnosis  can  arise,  and  we 
are  not  here  concerned  with  anything  deeper  or  more  accurate, 
the  discussion  of  which  indeed  involves  a  whole  treatise  on  trau- 
matic surgery.  If,  on  the  other  hand,  the  victim  is  unconscious 
though  not  dead  (again  vide  Sudden  Death),  and  no  history  obtain- 
able from  friends  or  bystanders,  the  patient  must  be  carefully 
examined  for  any  signs  of  injury  (fractured  base  of  skull,  or  severe 
crush,  bullet  wounds,  etc.),  and  then,  should  nothing  be  found  to 
account  for  the  unconsciousness,  the  case  must  temporarily  be 
placed  as  "  unconsciousness  "  amongst  the  group  of  nervous  lesions, 
and  its  diagnosis  sought  by  means  of  the  indications  given  under 


IX  URGENCY  CASES  329 

that  heading.  The  position  of  the  body,  as  at  the  bottom  of  a 
ladder  or  stairs,  etc.,  may  suggest  a  fall,  but  even  if  the  fall  be 
proved,  it  may  still  be  due  to  epilepsy,  apoplexy,  etc.  The  shock 
of  traumatism,  especially  if  the  latter  be  not  very  severe,  may 
take  the  shape  of  a  mental  condition  closely  resembling  alco- 
holism {q.v.). 

Group  IV. — Sudden  Death 

The  interest  of  this  group  is  purely  medico-legal.  There  can  be 
no  clinical  diagnostic  problem  involved,  unless  it  be  to  give  a  warn- 
ing to  friends  as  to  the  possible  sudden  death  of  any  patient,  so 
that  worldly  affairs  may  be  put  in  order  in  time.  It  is,  however, 
impossible  to  ignore  the  condition  in  an  article  on  "  Emergency 
Cases,"  and  so  I  have  inserted  the  following  table,  which  is  but 
slightly  altered  from  Professor  Dixon  Mann's  article  in  the  Lancet 
for  June  26,  1897  ;  the  great  assistance  of  which  I  wish  to  acknow- 
ledge. Dr.  Mann  states  that  in  a  case  of  sudden  death  one  of 
three  conditions  will  be  found  on  autopsy : — 

1.  A  recognisable  disease  or  condition  known  to  be  commonly 

associated  with  a  sudden  end. 

2.  A  recognisable  disease,  but  which  is  not  usually  terminated 

suddenly. 

3.  No    recognisable    pathological    condition    anywhere    in   the 

body. 

Tabulated  and  arranged,  with  a  few  additions  and  alterations, 
this  first  list  gives  the  following : — 

{a)   Morbus    cordis    (in    about     Valvular  disease. 

half  the  cases. — Mann).      Possibly  congenital  abnormality. 

Atheroma  of  coronary  arteries  (with  or 
without  history  of  angina  pectoris). 

Fatty  heart. 

Sclerosis  of  muscle. 

Rupture  of  wall  of  a  cavity. 
{b)   Haemorrhage.  Ruptured  aneurysm. 

Ruptured  spleen. 

Into  pancreas. 

Into  brain  (apoplexy). 

Into  stomach  or  intestine. 

Ectopic  gestation. 

Varicose  veins,  internal  or  external. 

Traumatism  of  a  large  vessel. 


33°  DIFFERENTIAL  DIAGNOSIS  chap. 

{c)  Asphyxia,  with  a  condition     Air,    serum,   blood,   or  pus   in   pleural 
or  disease  known  to  pro-  cavity. 

duce  it  rapidly.  CEdema  of,  or  membrane  in,  glottis  or 

polypoid  growth. 
Pressure  of  tumour  (solid  or  liquid)  on 

larynx  or  trachea. 
Embolus  of  air  in  a  vein,  or  clot  in  a 

pulmonary  artery. 
Blood,  or  other  vomited  or  swallowed 
foreign  body  in  air  passages. 
{d)   Miscellaneous    group,     in     Perforation  or  strangulation  of  gut,  and 
which  precise   mode   of         peritonitis, 
death    not    obvious.     Exophthalmic  goitre, 
though  the  morbid  con-     Addison's  disease, 
dition  is  easily  recognis-     Nephritis  of  any  kind, 
able,   and  is  known  on     Pneumonia,  especially  in  old  people, 
occasions  to  cause  very     Abscess  or  tumour  of  brain, 
rapid  death.  Meningitis. 

Obvious  damage  to  a  viscus  from  trau- 
matism. 

In  his  second  list  Professor  Mann  includes  some  of  the  con- 
ditions I  have  put  in  the  first  one,  and  also  the  following : — 

Diphtheria,  without  membrane  being  the  apparent  cause ;  prob- 
ably neuritis. 

Phthisis,  with  exhaustion  probably. 

Ulcerative  endocarditis ;  may  be  signs  of  septic  infarction. 

Pericarditis,  with  effusion  of  serum  or  pus. 

Adherent  pericardium,  probably  with  recognisable  changes  in 
the  muscle  of  the  heart. 

Gall-stone  colic  ]  May  find   the    stone  in  the  duct  or    ureter, 

Nephritic  colic  J       but  it  may  have  sHpped  back  or  out. 

Gout,  especially  in  corpulent  individuals,  recognised  probably 
by  the  cirrhotic  kidney  corroborating  the  joints  or  tophi. 

Hydatid  tumour,  which  has  ruptured. 

The  third  list  of  Professor  Mann's  I  have  enlarged  by  including 
in  it  several  conditions  which  he  has  placed  in  the  first  and  second; 
my  reason  for  so  doing  is  that  it  is  only  in  very  exceptional  circum- 
stances that  the  results  of  the  autopsy  are  sufficient  for  a  diagnosis ; 
there  is  required  in  addition  a  reliable  history  of  the  patient  in  some 
form,  or  a  witnessing  of  the  last  scene.     It  includes : — 


IX  URGENCY  CASES  331 

Asthma — possible  signs  of  asphyxia. 

Pertussis — possible  signs  of  asphyxia. 

Overlaying  of  infants. 

Epilepsy — possible  signs  of  asphyxia  ;  "i  /i  -ki 

,,--,         1  •         •       ,  •!  T  f      anQ  possiDiy 

Convulsions  m  children ;  L       i       v.'         f 

Spasm  of  glottis — possible  signs  of  asphyxia ;  T  i       _. 

(Laryngismus  stridulus) ;  ) 

Acute  rheumatism — cardiac  syncope. 
Zymotic  diseases — occasionally  by  intensity  of  the  poisoning — 

without  a  rash. 
Hyperpyrexia — sunstroke,  acute  rheumatism,  etc. 
Influenza. 
Excitement  or  fright  as  in  quarrelling,  or  near  approach  of  any 

danger — thought  of  an  operation,  etc. 
Chronic  alcoholism — probably  some  neuritis  of  pneumogastric. 

On  these  lists  I  do  not  propose  to  say  anything  further ;  their 
importance  is  obvious  and  enormous ;  but  when  we  have  admitted 
the  fact  of  sudden  death,  and  have  made  a  thoroughly  careful  post- 
mortem, clinical  medicine  ceases  its  functions,  and  legal  procedures 
come  to  the  front  with  all  the  available  evidence  as  to  what  was 
happening,  or  had  just  happened,  when  death  took  place. 

We  now  come  to  the  two  groups  which  include  the  real 
crux  of  the  position,  and  are  the  essential  clinical  elements  in 
drunk  or  dying.  They  must  be  considered  in.  some  considerable 
detail. 


Group  V. — Lesions  and  Conditions  of  the  Nervous  System 

Cerebral  plugging  or  rupture  of  a  vessel,  constituting  apoplexy 

of  the  laity. 
Epilepsy — including  post-epileptic  states,  and  also  malingering 

of  fits. 
Hysteria. 

Plumbism — lead  encephalopathy. 
Lunacy — especially  G.P.I. 

Cerebral  tumour — with  epileptiform  convulsions. 
Sunstroke. 
Meningitis,  and  acute  encephalitis. 

(Simple  fainting  will  be  here  considered;  as  its  main  symptom 
is  apparently  cerebral.) 


332  DIFFERENTIAL  DIAGNOSIS  chap. 

Group  VI. — Poisoning,  including  two  Sub-Groups 

A.  Autogenetic.  Uraemia. 

Diabetic  coma. 

B.  From   without,  which   may  include  any  and   every  poison, 

however  administered,  but  from  our  present  point  of  view 
has  especial  reference  to — 

Alcohol. 

Opium  and  other  narcotics,  such  as  chloral. 

Belladonna  as  a  deliriant. 
Strychnia  as  a  convulsant. 

Both  for  diagnosis  and  treatment  it  will  be  well  to  maintain  a 
chronological  order  of  events,  as  this  will  render  the  discussion 
much  more  practical,  even  if  it  introduces  a  little  theoretical  incon- 
sistency. 

Commencing  then  with  the  history.  While  getting  ready  to  go 
or  going  with  the  messenger  we  must  inquire  into  the  particulars  of 
the  seizure  as  closely  as  possible  :  asking,  for  instance,  Has  the  patient 
taken  anything  ? — if  so.  Of  what  known  nature  ? — Whence  obtained  ? 
— Is  he  in  a  fit  ?  etc.  From  the  answers  to  these  questions,  if  they 
be  intelligent  or  even  intelligible,  valuable  hints  may  be  obtained, 
I  am  bound  to  admit  that  in  the  majority  of  cases  there  will  be 
either  no  history  at  all,  owing  to  the  absence  of  witnesses,  or  the 
history  will  be  unintelligible,  owing  to  the  anxiety,  fright,  or  imbe- 
cility of  the  messenger ;  or,  again,  it  may  be  purposely  misleading 
in  some  few  criminal  cases.  Such  as  it  is,  however,  listen  to  it, 
and  use  your  own  judgment  as  to  its  value. 

On  arrival,  the  first  thing  is  to  clear  the  room  or  a  space  round 
the  individual,  to  give  him  air,  to  prevent  bystanders  doing  mis- 
chief, and  to  enable  you  to  exert  your  own  efforts  without  unneces- 
sary interruption.  Secondly,  while  doing  this,  you  will  have  a  few 
moments  in  which  to  note  the  general  aspect  of  the  patient.  Is  he 
motionless  and  apparently  dead,  or  is  he  in  a  fit,  convulsed  and 
obviously  living  ?  Is  his  face  natural  in  colour,  or  is  it  blue  with 
livid  lips,  and  is  froth  issuing  from  them  ? — if  so.  Is  the  froth  blood- 
stained ?  Is  he  sweating  profusely,  or  is  his  face  dry  ?  Thirdly, 
while  noticing  these  facts  loosen  everything  from  the  neck,  cutting 
the  clothes  if  necessary  for  rapid  action  to  prevent  imminent 
asphyxia.  And  lastly,  if  convulsed,  restrain  him  in  some  way,  so 
as  to  prevent  him  from  injuring  himself  by  the  violence  of  his 
movements. 


IX  URGENCY  CASES  333 

We  are  now  in  a  position  to  take  diagnosis  into  consideration, 
and  this  obviously  proceeds  in  two  directions,  according  to  whether 
the  patient  has  convulsions  and  is  living,  or  whether  he  is  quiet  and 
possibly  dead. 

If  he  is  in  a  "  fit,"  this  may  be  due  to — 

Cerebral  (hcemorrhage,  tumour,  etc.); 

Epilepsy ; 

Hysteria  ; 

Malingering  ; 

Poisoning — strychnine  especially,  but  possibly  opium  or  other 

poison ; 
Uraemia  ; 

Dentition,  etc.,  in  babies ; 
Tetanus ; 

and  the  following  are  the  points  most  worth  attention  to   decide 
which  of  these  is  present. 

1.  Age  and  Sex. — Of  age  little  need  be  said,  for  at  all  ages 
many  things  are  possible.  It  is  obvious  that  dentition  can  only 
occur  in  babies,  and  in  these  young  subjects  convulsions  are  very 
common  from  every  form  of  reflex  irritation ;  the  precise  cause  can 
only  be  cleared  up  by  the  same  careful  examination  as  in  adults  j 
the  condition,  though  very  common,  hardly  gives  rise  to  difficulties  in 
our  present  connection,/.^,  with  "urgency."  Sex,  too,  has  only 
this  influence,  that  in  females,  and  especially  from  seventeen  to  forty 
years  of  age,  we  lean  more  strongly  to  a  diagnosis  of  functional 
trouble  of  no  great  immediate  danger. 

2.  The  Eyes. — A  most,  perhaps  the  most,  important  seat  of 
clues. 

Are  they  open  or  shut  ? — if  shut.  Is  there  much  resistance  to  your 
opening  them  by  lifting  the  lids? — Is  the  patient  looking  round 
furtively  ?  This  furtive  glancing  and  resistance  to  opening  the  eyes 
is  very  suggestive  indeed  of  hysteria  or  malingering.  Then  the  state 
of  the  pupils,  note  are  they  equal  or  unequal,  dilated  or  contracted, 
do  they  react  to  hght  or  not,  is  the  conjunctival  reflex  present.  In 
epilepsy  the  pupils  are  dilated  and  insensible  to  light,  or  occasionally 
oscillating  without  obvious  cause :  in  hysteria  they  react  readily  to 
light,  and  in  malingering  (unless  artificially  tampered  with)  they  will 
obviously  do  the  same.  In  poisoning  they  will  usually  not  act  to 
light,  if  it  be  by  strychnine,  the  only  likely  convulsant,  they  will  be 
dilated,  as  will  also  happen  if  asphyxial  convulsions  are  due  to  some 
poison;  should  it  happen  to  be  a  case  of  opium  poisoning  with 


334  DIFFERENTIAL  DIAGNOSIS  chap. 

convulsions  they  will  be  contracted.  In  uraemia  the  pupils  are  as  a 
rule  fixed  and  dilated,  they  react  very  slowly,  if  at  all,  to  light,  but  it 
may  happen  that  they  are  of  natural  size.  If  the  pupils  are  unequal 
we  shall  think  of  pontine  or  other  cerebral  haemorrhage,  or  of 
general  paralysis  of  the  insane.  The  conjunctival  reflex  will  be 
absent  in  'epilepsy,  uraemia,  and  other  more  dangerous  conditions ; 
certainly  present  in  hysteria  and  malingering. 

We  may  sum  up  the  matter  by  saying  that  if  ( i )  fixed  (small  or 
large),  or  (2)  irregular  and  unequal,  pupils  are  present,  or  if  (3)  the 
conjunctival  reflex  is  absent,  then  the  condition  is  serious,  and  may 
be  a  dangerous  one.  If,  on  the  other  hand,  the  pupils  react  readily 
to  light,  it  is  probably  a  less  serious  matter,  and  if  the  conjunctival 
reflex  is  present  this  adds  greatly  to  the  probability  of  a  recoverable 
condition. 

3.  Froth  coming  from  Mouth,  —  This  is  usually  present  in 
epilepsy,  and  very  possibly  blood-stained  from  biting  of  the  tongue. 
If  it  be  blood-stained,  epilepsy  is  certainly  most  probable  in  the 
absence  of  motive  for  malingering.  Malingerers  will  use  soap  for 
froth-making  purposes,  so  that  the  mouth  must  be  examined  for  this 
article.  Froth  may  be  present  in  poisoning,  but  has  then  no  special 
significance  except  as  suggesting  hydrocyanic  acid,  but  then  fits  are 
not  present. 

4.  Note  the  Nature  of  the  Convulsions. — They  are  most  exag- 
gerated perhaps  in  hysteria,  and  most  universal.  The  malingerer  is 
apt  to  over-  or  under-do  the  movements.  In  poisoning  by  strych- 
nine an  attack  is  soon  over  and  followed  by  complete  relaxation  of 
muscles ;  in  tetanus  this  relaxation  is  incomplete  ;  moreover  strych- 
nine convulsions  are  more  marked  in  head  and  trunk  (opisthotonos 
or  emprosthotonos),  while  tetanus  is  more  likely  to  be  concentrated 
in  the  jaws  and  neck.  In  epilepsy,  too,  opisthotonos  is  usually 
absent,  and  malingerers  cannot  keep  it  up  for  long,  even  if  they  can 
assume  the  position  at  all.  In  cerebral  haemorrhage  or  blocking 
with  convulsive  movements,  these  will  take  the  shape  of  conjugate 
deviation  of  head  and  eyes,  a  most  important  sign,  hardly  ever  met 
with  except  with  such  gross  lesion. 

5.  The  General  Appearance  of  the  Face. — In  malingerers  certainly, 
and  usually  in  hysteria,  the  face  is  hot  and  flushed,  and  the  body  as 
well  bathed  in  hot  perspiration  (note  the  state  of  the  weather  or 
atmospheric  pressure)  if  the  movements  are  at  all  violent.  In  epi- 
lepsy the  face  is  possibly  blue  and  congested,  or  more  probably 
pale ;  it  may  be  moist,  but  it  will  be  with  a  cold  sweat,  and  the 
same  coldness  will  be  present  in  poisoning.     In  uraemia  the  face 


IX  URGENCY  CASES  335 

may  be  flushed,  but  it  is  more  usually  natural  or  pale  without 
sweat. 

6.  The  Getter al  Coftscioitsness  and  Capability  of  being  Roused  to 
Speech. — In  malingering  and  hysteria  he  can  certainly  be  roused ; 
in  epilepsy  and  uraemia  he  cannot  be ;  in  poisoning  he  is  either 
totally  unconscious  (hardly  in  this  group),  or  is  perfectly  conscious 
and  rational  between  the  fits. 

7.  The  Pulse. — Over  this  the  patient  can  have  no  control.  In 
malingering  and  hysteria  the  pulse  will  be  full,  bounding,  and  rapid 
from  exertion.  In  uraemia  and  poisoning  it  is  likely  to  be  very 
small  and  rapid ;  in  epilepsy  it  is  usually  somewhat  accelerated  ;  in 
gross  cerebral  lesions  it  is  likely  to  be  very  slow,  from  cerebral  com- 
pression. 

Such  are  the  most  important  means  of  immediate  or  rough 
diagnosis,  none  of  them  individually  trustworthy ;  each  has  to  be 
considered  in  relation  to  the  others.  I  do  not  propose  to  consider 
the  more  accurate  diagnosis  any  further,  as  the  main  object  of  this 
chapter  is  to  draw  a  line  between  those  cases  for  which  a  bucket  of 
water  or  a  police  cell  is  advisable,  and  those  for  which  skilled 
medical  attention  in  a  place  of  rest  and  quietude  (bed  at  home,  or 
in  a  hospital)  is  the  only  safe  line  to  pursue. 

We  will  now  pass  on  to  the  second  group  of  cases,  viz.  those  in 
which  convulsions  with  (genuine  or  feigned)  unconsciousness  are  not 
present.  Here  the  cases  may  be  divided  into  three  classes,  though 
I  shall  speak  of  them  only  in  two : — 

/. — Those  who  are  actively  conscious  (this  consciousness  may  be 
very  perverted  in  its  judgment),  and  perhaps  noisy  and  abusive, 
especially  when  undergoing  physical  examination. 

// — Those  who  are  unconscious,  but  can  be  roused  by  speaking, 
pinching,  pricking,  etc. 

///. — Those  who  are  absolutely  comatose,  and  cannot  be  roused 
at  all. 

Firstly,  then,  those  who  are  actively  conscious  and  may  be  noisy. 
Practically  there  are  four  things  to  be  thought  of  here : — ■ 

( 1 )  Alcoholism — drunkenness  ; 

(2)  Head  injuries  and  cerebral  disease; 

(3)  Lunacy; 

(4)  Poisoning  other  than  alcohol — rarely ; 

and  it  must  never  be  forgotten  that  the  first  may  be  combined  with 
any  of  the  others  ;  a  complication  the  possibility  of  which  forms  the 
principal  crux  of  the  problem. 


336  DIFFERENTIAL  DIAGNOSIS  chap. 

Here  again,  the  first  thing  is  the  history  from  others  or  from  the 
patient,  and  it  is  very  probable  that  in  this  class  of  cases  it  will 
throw  strong  light  on  the  diagnosis,  especially  when  taken  with  the 
manner  in  which  it  is  told. 

Lunacy,  under  these  particular  circumstances,  is  almost  sure 
to  betray  itself  either  by  the  absolute  nonsense  the  patient  talks,  or 
by  the  direct  contradiction  of,  or  lack  of  confirmation  from,  the 
story  of  those  with  him.  The  manner  of  relating  his  tale  differs 
materially  in  the  lunatic  and  the  "drunk,"  The  lunatic  may  relate 
his  tale  perfectly  quietly  and  with  pseudo- rationality,  the  drunken 
man  is  nearly  sure  (in  this  stage)  to  be  very  excitable  and  inco- 
herent :  the  speech  of  the  former  will  be  complete  in  its  individual 
words  (except  in  general  paralysis  of  the  insane,  when  the  long  words 
may  be  slurred),  that  of  the  latter  will  have  the  easily  recognised 
character  of  drunken  speech. 

If  actual  lunacy  can  be  excluded,  but  we  have  a  strong  suspicion 
that  alcohol  has  been  at  work  with  or  without  an  accident  of  some 
kind,  the  tale  of  others  may  be  of  most  material  value.  In  cases  of 
head  trouble,  whether  from  traumatism  (shock  is  here  an  important 
element)  or  from  disease,  a  little  alcohol  goes  a  long  way,  so  that  if 
there  be  the  slightest  suspicion  of  serious  trouble,  abuse  and  noisi- 
ness must  be  largely  discounted,  and  the  patient  taken  under  pro- 
fessional care.  A  case  in  point  occurred  within  my  experience  some 
years  ago.  The  patient  was  at  first  quiet,  but  began  to  be  noisy, 
abusive,  and  very  pugnacious  when  examined.  He  was  thought  to 
be  drunk,  and  was  on  the  point  of  being  sent  away  when  another 
house  physician  saw  him,  thought  he  looked  very  ill  and  peculiar, 
and  advised  his  admission  to  the  wards :  he  died  before  reaching 
them,  and  the  autopsy  showed  that  it  was  a  case  of  cerebro-spinal 
meningitis.  See,  therefore,  how  noisy  and  abusive  conversation  fits 
in  with  other  facts  in  the  history. 

If  what  you  hear  is  not  sufficient,  see  what  you  can  ascertain 
with  your  eyes.  The  colour  and  appearance  of  the  face  may  help. 
In  alcoholism  it  will  be  flushed ;  in  head  mischief,  whether  haemor- 
rhage or  inflammation,  the  face  is  possibly  flushed,  but  it  is  much 
more  likely  to  be  pale,  or  blue  and  congested — bloated ;  in  a  lunatic 
the  face  will  seem  natural,  or  possibly  flushed  with  exertion ;  in 
deliriant  poisoning  the  face  will  be  dry  and  flushed,  or  cold  and 
clammy.  The  condition  of  the  pupils  is  as  important  here  as  in 
the  case  of  convulsions ;  in  alcoholism  they  are  sure  to  be  dilated, 
and  probably  fairly  active ;  indeed,  if  the  patient  is  not  comatose 
from    alcohol    they   are   sure    to   be   active.     In   head   conditions, 


IX  URGENCY  CASES  337 

though  the  pupils  may  be  active,  they  are  more  likely  to  be  fixed, 
dilated,  contracted,  or  unequal,  or  at  least  sluggish  in  movement. 
In  lunatics  (except  general  paralysis,  when  they  are  unequal  or 
sluggish)  they  are  active  enough.  In  poisoning  in  this  stage  they 
would  be  widely  dilated  and  inactive,  with  brightly  glistening  eyes. 

If  still  in  doubt  the  temperature  should  be  taken.  This  in 
serious  cases  is  pretty  sure  to  be  markedly  raised  or  lowered.  If  a 
normal  temperature  is  found  in  a  man  who  is  actively  conscious,  or 
can  be  roused  very  easily,  and  if  at  the  same  time  his  pupils  are 
active,  the  probabilities  are  that  there  is  nothing  very  serious  the 
matter.  If,  on  the  other  hand,  the  temperature  is  raised,  inflam- 
matory conditions  must  be  suspected,  either  in  the  brain  or  possibly 
elsewhere  (unsuspected  pneumonia,  e.g.),  and  if  markedly  lowered 
we  know  that  there  is  a  depression  likely  enough  to  be  or  become 
dangerous,  and  the  case  had  better  be  watched. 

These  points,  if  carefully  considered,  will  be,  as  a  rule,  sufficient 
to  prevent  serious  mistakes,  but  keep  all  your  faculties  on  the  stretch 
for  any  little  suggestive  point ;  finally,  if  in  doubt,  act  as  if  the  case 
were  a  serious  one. 

We  will  now  pass  on  to  the  other  group  of  cases — those  in 
which  the  patient  is  quiet  and  actually  unconscious,  though  he  may 
be  capable  of  being  roused  momentarily. 

There  is  here  only  one  golden  rule  of  treatment :  Never  allow 

AN  UNCONSCIOUS   PATIENT    TO    BE    LEFT  ALONE.        If   hc    is    SCCU    at    a 

hospital  take  him  in.  Far  better  to  take  in  fifty  drunken  men  in 
one  night,  and  let  them  lie  on  mattresses  under  supervision  in  a 
warm  room,  than  let  one  die  unattended.  The  one  action  can  at 
the  worst  only  subject  you  to  mild  chaff  and  cause  temporary  incon- 
venience, the  other  may  ruin  you  or  your  hospital  for  ever.  If  seen 
elsewhere  than  at  a  hospital  have  him  removed  at  once  to  a  hospital 
or  to  his  home  (or  some  one  else's),  and  do  not  leave  him  till  some 
reliable  person  is  in  charge.  This  is  a  golden  rule,  from  w^hich  no 
possible  concurrence  of  circumstances  should  ever  allow  you  to 
depart. 

Accurate  diagnosis  is  therefore,  from  the  point  of  view  of  imme- 
diate treatment,  but  of  little  use,  but  for  further  treatment,  and  for 
our  reputations'  sake,  we  must  endeavour  to  make  one. 

Any  one  of  the  conditions  hitherto  enumerated  in  this  chapter 
may  be  present,  or  a  combination  of  tw^o  or  more.  A  drunken  man, 
for  instance,  is  not  absolutely  free  from  the  chance  of  being  injured 
by  blows  or  falls,  and  he  is  even  more  likely  than  a  sober  one, 
i:efen's  paribus^  to  have  an  intracranial  haemorrhage,  for  if  a  man's 

z 


338  DIFFERENTIAL  DIAGNOSIS  chap. 

vessels  are  diseased  and  he  gets  drunk,  the  arteries,  which  can  do 
so,  dilate,  the  diseased  ones  cannot,  and  rupture  may  occur.  A 
hysterical  woman  may  have  a  genuine  epileptic  fit  with  post-epileptic 
coma,  and  she  may  have  got  drunk  previous  to  either,  and  finally 
have  been  damaged. 

Your  preliminary  actions  are  here  the  same  as  in  the  other 
groups.  Clear  a  space  round  the  patient,  free  his  neck,  listen  to 
any  history  that  is  forthcomiing,  and  if  definitely  pointing  to  poison 
act  promptly  on  it.  Do  not  forget  that  coma  from  alcohol  is  as 
much  poisoning  by  that  substance,  and  often  as  dangerous,  as  is 
poisoning  by  opium  or  any  other  drug. 

S?nell  the  Bi'eath. — In  the  absence  of  a  definite  reliable  history 
(either  of  an  alcoholic  bout  or  of  only  one  glass  given  by  anxious 
friends)  the  smell  of  alcohol  is  of  equal  importance  with  the  smell 
of  other  poisonous  substances.  If  a  definite  history  is  forthcoming 
an  alcoholic  smell  must  be  judged  by  it. 

Camphor,  turpentine,  carbolic  acid,  hydrocyanic  acid,  chloro- 
form, aether,  opium  are  the  principal  commoner  poisons  that  will 
have  imparted  a  distinctive  odour  to  the  breath.  In  diabetic 
coma  the  breath  will  be  sweet  like  apples.  Lately,  on  entering  a 
patient's  bedroom,  I  thought  I  had  gone  by  mistake  into  an  apple 
storeroom.  Occasionally  patients  in  uraemic  coma  are  said  to 
smell  of  ammionia. 

Note  the  Face  as  Before. — If  it  is  pale  and  dry  the  case  is  quite 
likely  to  be  only  simple  fainting,  if  there  are  no  other  distinctive 
symptoms ;  if  it  is  pale  and  sweaty,  with  cyanosed  lips,  cerebral 
haemorrhage  or  poisoning  are  most  probable ;  if  flushed  brightly 
it  may  be  alcohol  or  belladonna  poisoning,  or  possibly  fever;  if 
the  face  be  purple  and  bloated,  this  points  almost  conclusively  to 
serious  cerebral  mischief,  probably  compression. 

Next  Proceed  to  Examine  the  Pupils. — In  the  other  sections  we 
have  already  considered  the  broad  outlines  of  the  conclusions  to 
be  drawn  from  the  condition  of  the  pupils.  We  may  here  finally 
tabulate  the  possible  conditions,  with  a  few  remarks  on  their  special 
influence  on  final  diagnosis. 

The  pupils  may  be — - 

As  regards  As  regards  As  regards 

Reaction  to  Light.  Absolute  Size.  Relative  Size. 

Active.  Dilated.  Equal. 

Sluggish.  Normal.  Unequal. 

Totally  inactive.  Contracted. 

And  finally  either  one  or  both  may  be  irregular  in  outline. 


IX  URGENCY  CASES  339 

Conditions  in  which  the  Pupils  are  still  Active. — This  is  only 
likely  to  be  the  case  when  the  condition  of  the  brain  causing  the 
unconsciousness  is  either  of  a  temporary  character  or  in  a  very 
early  stage.  Inasmuch  as  we  can  but  rarely  see  the  patient  in 
the  latter  condition,  it  is  almost  a  fair  clinical  deduction  to  say 
that  still  very  active  pupils  indicate  no  immediate  danger.  Thus 
they  will  be  found  in  malingerers,  in  simple  fainting  (then  indica- 
tive of  returning  consciousness),  in  hysterical  and  cataleptic  con- 
ditions, and  in  the  later  stages  of  post-epileptic  coma  that  is  not 
going  to  prove  fatal.  The  malingerer  may  be  aware  that  he  can, 
by  stimulating  the  palm,  dilate  the  pupil  on  that  side,  but  this 
is  such  a  temporary  phenomenon  as  to  cause  little  or  no  difficulty. 
In  poisoning  the  pupils  are  frequently  unaffected  in  the  early  stages, 
but  this  can  hardly  occur  when  absorption  has  so  far  advanced  as 
to  cause  coma.  The  absolute  size  of  active  pupils  will  depend 
upon  the  amount  of  light  in  the  examination  room 

•  Conditions  in  which  the  Pupils  are  Sluggish 

This  occurs  in — 

General  paralysis  of  in-  They  will  probably  also  be  unequal,  and 
sane.  behave   otherwise   in    a    bizarre    manner, 

possibly  dilating  with  light. 

Uraemia.  ^vlay  be  small,  natural  in  size,  or  dilated. 

Disseminated  sclerosis.  In  any  condition,  like  ursemia. 

Early  stages  of  apoplexy.  Will  probably  cease  to  act  before  the  ex- 
amination is  completed. 

Conditions  in  which  the  Pupil  ceases  to  React  to  Light  at  all 

The  first  and  most  important  deduction  from  this  state  of  the 
pupils  (if  we  can  exclude  a  glass  eye  and  previous  total  blindness) 
is  that  the  condition  of  brain  underlying  it  is  very  serious,  and  even 
likely  to  prove  fatal ;  it  marks  the  dividing  line  between  coma  and 
stupor. 

The  commonest  examples  are  : — 

Pupils  very  small.  Opium  poisoning  (very  rarely  dilated). 

Pontine  hsemoiThage  (also  often  unequal). 
Possibly  in  general  paralysis  of  the  insane,  or  in 
tabes  dorsalis. 
Pupils     large      and      Belladonna  (and  its  allies)  poisoning,  and  also  in 
equal.  the  later  stages  of  most   poisons,  especially  if 


340  DIFFERENTIAL  DIAGNOSIS  chap. 

asphyxia  is  or  has  been  a  prominent  feature. 
In  connection  with  the  large  pupils  of  alcoholic 
poisoning  it  is  worth  while  to  note  that  even 
in  a  condition  of  coma  due  to  this  cause  the 
pupils  will  still  react  to  powerful  peripheral 
stimuli,  such  as  pinching  the  patient  or  pulling 
his  hair  forcibly.  I  know  of  no  other  grave 
condition  of  which  this  can  be  said. 
Pupils  unequal.  Frequent  in  one-sided  pontine  lesions.     Also  in 

one-sided  considerable  increase  in  intracranial 
pressure,  as  from  haemorrhage. 
In  general  paralysis,  too,  it  may  continue  during 
a  final  coma  if  previously  present. 

After  the  examination  of  the  eyes  look  for  localised  paralyses 
anywhere.  Is  the  face  reasonably  symmetrical  ?  Are  the  eyes  in  a 
natural  axis  or  markedly  deviating  ?  Do  the  arms  or  the  legs  drop 
equally  powerlessly  when  raised  ? 

A  localised  paralysis  of  this  sort  is  almost  pathognomonic  cJf 
coarse  cerebral  lesion,  but  of  course  in  deep  coma  the  point  is  often 
difficult  to  appreciate. 

The  next  point  is  the  respiration.  If  this  is  stertorous  the 
probabilities  are  in  favour  of  a  cerebral  lesion ;  but  one  must  not 
forget  that  it  may  become  stertorous  in  every  form  of  dangerous 
coma. 

Then  the  pulse.  If  it  be  small,  compressible,  and  slow,  it  is 
very  likely  to  be  opium  poisoning  (occasionally  opium  produces  a 
very  rapid  pulse)  or  pontine  lesion.  If  it  be  small  and  thready  and 
rapid,  no  conclusion  can  be  drawn,  as  this  pulse  is  met  with  in  so 
many  conditions  of  coma  where  death  threatens.  A  slow,  labouring 
pulse,  especially  with  a  thickened  artery,  is  suggestive  of  cerebral 
haemorrhage,  or  post-epileptic  coma. 

Now  draw  off  some  of  the  urine.  If  sugar  be  present,  diabetic 
coma  is  rendered  probable  though  it  occurs  when  anything  presses 
on  the  fourth  ventricle  ;  e.g.  I  have  found  it  in  cerebellar  haemorrhage. 
If  it  is  urasmic  coma,  there  is  likely  to  be  albumen,  or  possibly  blood, 
or  both,  and  the  urine  will  be  of  low  specific  gravity ;  this  latter  is 
especially  important,  as  the  urine  of  cirrhotic  kidney  often  enough 
contains  no  albumen,  or  such  a  faint  trace  as  to  be  easily 
overlooked.  A  cirrhotic  kidney,  too,  renders  haemorrhage  very 
likely. 

After  noting  the  foregoing  points,  try  how  far  the  patient  is  capable 
of  being  roused  ;  the  danger  increases  pari  passu  with  the  depth  of 


IX  URGENCY  CASES  341 

the  coma.  In  uraemia,  even  when  likely  to  prove  fatal,  some  signs 
of  consciousness  can  usually  be  obtained  by  pretty  forcible  stimula- 
tion ;  this  forms  a  valuable — not  conclusive — distinction  between 
uraemia  and  the  coma  of  cerebral  hcemorrhage. 

Lastly,  take  the  temperature.  This  may  give  some  information; 
it  will  be  very  high  in  sunstroke  or  other  forms  of  heat  apoplexy, 
and  gives  instantly  the  best  guide  to  treatment.  It  almost  certainly 
will  be  raised  in  the  comatose  condition  of  general  paralytics,  or  of 
inflammatory  conditions,  and  hence  will  be  of  great  use  in  separating 
these  from  haemorrhage,  uraemia,  etc.,  in  which  the  temperature  (at 
the  time  we  are  considering)  is  invariably  subnormal. 

In  conclusion,  I  must  again  repeat  that  no  one  of  these  indica- 
tions is  sufficient  by  itself;  all  must  be  considered  and  a  balance 
struck.  The  history  may  be  absolutely  conclusive,  and  now  and  again 
an  individual  feature  (e.g.  conjugate  deviation)  may  be  so  marked 
and  obtrusive  as  to  outweigh  everything ;  but  whatever  conclusion 
we   finally  arrive   at,  we  must   never  leave  a  comatose  patient 

WITHOUT  EFFICIENT  SUPERVISION  ;  HE  MUST  ALWAYS  BE  WATCHED 
carefully  TILL  A  SUFFICIENT  TIME  HAS  ELAPSED  TO  ALLOW  OF 
AN    ALCOHOLIC    COMPLICATION    HAVING    PASSED    OFF. 


INDEX 


Abdomen,  pain  in,  vide  Colic 

physical  examination  of,  i68 

Abortive  zymotics,  meaning  of,  31 
Abscess,  of  lung,  foetid  sputum  in,  56 

V.  tumour,  of  brain,  316 

Acid,  uric,  209 

Addison's  disease,  pathology  of,  23 
Adenoids  as  cause  of  epistaxis,  149 
Adhesions  as  cause  of  abdominal  pain, 

63 
Age  and  chronic  bronchitis,  99 

and  disease,  12 

and  tubercle,  238 

in  hemiplegia,  318 

old,  shortness  of  breath  in,  58 

Ague  V.  ulcerative  endocarditis,  145 
Air  in  pleura,  causes  of,  80 
Air-tubes,  pressure  effects  on,  59 
Albuminuria,  195 

cyclical  or  functional,  196 

eye  changes  in,  324 

treatment  of,  199 

Alcoholism,  coma  in,  338 

• inco-ordination  in,  269 

in  urgency  cases,  336 

peripheral  neuritis  in,  283 

pupils  in,  336,  340 

shock  in,  329 

tremors  of,  311 

Anaemia,  cardiac  bruits  in,  129 

eye  changes  in,  324 

nervous  phenomena  in,  273 

respiration  quickened  in,  57 

Anaesthesia,  paradoxical,  282 
Anchylostomiasis,  156 
Aneurysm  as  cause  of  colic,  173 

as  cause  of  pressure,  61 

bruits  of,  V.  valvular  disease,  132 

pain  in,  61 

pressure  of,  on  cord,  290 

thoracic,  107 


Aneurysm,  treatment  of,  134 

V.  growth  in  thorax,  107 

Angina  pectoris  as  urgency  case,  328 
Antitoxin,  arguments  for  existence  of,  5 

in  diphtheria,  39 

special  or  general,  6 

Anviria,  causes  of,  217 

Anus,  blood  appearing  at,  156 

diseased  conditions  of,  176 

Aphasia,  motor,  305 
Apoplexy  and  sudden  death,  331 
Appendix  and  pain,  173 
Arsenic,  peripheral  neuritis  from,  283 
Arteries,  pressure  on,  in  thorax,  59 
Arterioles,    degeneration    of,    in  emphy- 
sema, 99 
Arthritic  diathesis,  the,  244 
Arthritis,  rheumatoid,  z/.  true  rheumatism, 

242 
Ascites,  177 

causes  of,  178 

purulent,  179 

tapping  V.  incision  for,  179 

V.  encysted  fluid,  181 

Asphyxia  and  sudden  death,  330 
Ataxic  paraplegia  v.  peripheral  neuritis, 

295 

Ataxy,  locomotor,  vide  Tabes  Dorsalis 

Athetosis,  311 

Atrophy,   progressive  muscular,   v.  peri- 
pheral neuritis,  293 

Auscultation  of  chest,  69 

Bacteriology,  principles  of,  25 
Ballooning  of  rectum,  176 
Barometer,  living,  meaning  of,  243 
Bell  sound  on  percussion,  73 
Bile  in  sputum,  55 

in  urine,  tests  for,  190 

Bladder,  causes  of  pus  from,  202 
haemorrhage  from,  204 


344 


DIFFERENTIAL  DIAGNOSIS 


Bladder  like  rectum,  265 

reflexes  of,  263 

Blood    dyscrasise    as     cause    of     nerve 

symptoms,  273 
Blood  from  kidneys  v.  from  bladder,  203 

in  urine,  203 

Blood-spitting,  causes  of,  54 
Bone,  features  of  pain  from,  60 

pressure  on,  in  thorax,  60 

Brain,  abscess  of,  v.  tumour,  316 

acute  vascular  lesions  of,  315 

difficulties  in  studying,  306 

diseases  of,  306 

haemorrhage  into,  v.  meninges,  317 

effect  of  heart  failure  on,  119 

functions  of,  255 

localisation  in,  307 

peduncles,  affections  of,  298 

softening  of,  P.M.  table,  320 

softening  of,  v.  haemorrhage,  318 

softening  of,  varieties  of,  320 

tumours  of,  322 

tumours  of,  headache  in,  323 

V.  cord,  lesions  of,  279 

white  matter,  functions  of,  308 

Breath,  foul,  v.  foetid  sputum,  56 

shortness  of,  in  heart  disease,  113 

shortness  of,  in  old  people,  58 

shortness  of,  v.  dyspncea,  58 

smell  of,  in  urgency  cases,  338 

sounds,  69 

Breathing,  cavernous,  72 

diaphragmatic,  58 

Bright' s  disease,  217 
Bronchiectasis,  99 

foetid  sputum  in,  56 

sputum  in,  53 

Bronchitis,     acute,     and     bronchopneu- 
monia, 97 
Bronchitis,  acute,  and  uraemia,  216 

acute,  cough  in,  50 

acute,  temperature  in,  48,  98 

acute,  V.  tubercle,  91 

capillary  pyrexia  in,  48,  100 

chronic,  and  its  associations,  98 

chronic,  and  phthisis,  94 

■  chronic,  complications  of,  99 

chronic,  blood-spitting  in,  54 

Bronchopneumonia  and  tubercle,  100 

and  chronic  bronchitis,  100 

pyrexia  in,  98 

P5Texia  in,  v.  bronchitis,  48 

V.  tubercle,  91 


Bruits,  exocardial  v.  endocardial, 

haemic  v.  organic,  129 

importance  of,  116 


127 


Bruits  of  aneurysm,  132 

valve  of  origin  of,  130 

vital  significance  of,  133 

Bulbar  paralysis,  321 

V.  haemorrhage,  321 

Bulging  of  chest,  66 
Bursae,  enlargement  of,  233 

Calcium  phosphate  in  urine,  208 
Capsule,  internal,  functions  of,  308 
Carcinoma     of     kidney     v.      stone    or 

tubercle,  224 
Caries  affecting  spinal  cord,  290 

as  cause  of  chest  pain,  61 

as  cause  of  colic,  173 

Case  taking,  instructions  for,  2 

Casts  in  urine,  205 

Cavernous  breathing,  72 

Cavity  in  lung,  signs  of,  84 

Cells  of  body,  disturbed  functions  of,  15 

of    body,    disturbed    functions    in 

blood-poisoning,  16 
Cells  of  nervous  system,  affections  of,  320 
Cerebellum,  functions  of,  307 

inco-ordination  from,  269 

Charcot's  joint,  231,  232,  235,  240 

Chemiotaxis,  definition  of,  29 

Chest,   comparison  of  two  sides  of,   64, 

65 
Chest,  inspection  of,  65 

oedema  of,  66,  108 

pain  in,  61 

palpation  of,  66 

tumour  of,  66 

veins  enlarged  on,  66 

wall,  bulging  of,  66 

Cheyne-Stokes  breathing,  58 
Children,  cholera  nostras  in,  43 
Cholera,  asiatica  v.  nostras,  43 
Chondroarthritis,  239 
Chorea  a  cortical  trouble,  311,  314 

and  traumatism,  312 

Choroid,  tubercle  in,  325 

Clicky  crepitations,  92 

Cogwheel  respiration,  72 

Cold  and  cough,  origin  of  phthisis  in,  92 

Colic,  161 

and  sudden  death,  330 

causes  of,  161 

differential  diagnosis  of,  163 

renal,  v.  biliary  or  intestinal,  171 

simple  V.  obstructive,  169 

with  collapse,  points  in,  165 

with  collapse,  operation  in,  165 

without  collapse,  167 

Coma  in  alcoholism,  338 


INDEX 


345 


Coma  in  uraemia  v.  cerebral  haemorrhage, 

341 
Coma,  temperature  in,  341 

V.  stupor,  pupils  in,  339 

Communicable  v.  infectious,  24 
Comparison  of  two  sides  of  chest,  64,  65 
Compensation  in  heart  disease,  120 
Concussion,  318 
Congenital  disease,  12 
Consciousness  in  hemiplegia,  319 
Constipation  and  diarrhoea,  173 

consideration  of,  175 

Contagion  v.  infection,  24 
Convulsions,  nature  of,  in  urgency  cases, 

334 

Convulsions  v.  rigors,  95 
Co-ordination  of  motion,  268 

of  sensation,  258 

Cord,      spinal,      continuation     of,      into 

medulla,  299 
Cord,  spinal,  diseases  of,  285 

function  of,  general,  255 

function  of  systems  of,  286 

gnmmata  of,  290 

lesions  of,  indiscriminate,  290 

lesions  of,  irritative  v.    destructive, 

290 
Cord,  spinal,  lesions  of,  system,  285 

meningitis  of,  290 

pressure  of  aneurysm  on,  290 

syphilis  of,  290 

V.  brain,  279 

Corona  radiata,  308 
Corpora  quadrigemina,  309 
Corpus  callosum,  308 

striatum,  308 

Cough,  at  night,  52 

classification  of,  49 

in  ear  trouble,  50 

in  heart  disease,  113 

in  lar}Tigeal  trouble,  50,  yj 

in  thoracic  tumours,  51 

useless,  causes  of,  50 

Coughing  during  auscultation,  84 
Cranial  nerves,  303,  305 
Crepitations,  clicky,  92 

definition  of,  70 

Cyst,  abdominal,  v.  ascites,  181 

Damage,  old,  and  elasticity  of  function, 

60 
Death,  sudden,  causes  of,  329 
Defaecation  and  micturition,  265 
Degeneration  as  process  of  disease,  16 

causes  of,  17 

reaction  of,  269 


Degeneration,  secondary,  17 
Delirium,  276 
Desquamation,  point  in,  36 
Diabetes,  insipidus,  227 

pathology  of,  213 

peripheral  neuritis  in,  283 

phosphatic,  227 

Diagnosis,  definition  of,  i 

second  stage  in,  4 

three  stages  in,  i,  5 

Diaphragmatic  breathing,  58 
Diarrhoea  and  constipation,  173 

and  constipation,  causes  of,  173 

and  uraemia,  216 

considerations  in  case  of,  174 

in  phthisis,  94,  177 

severe,  v.  cholera,  43 

Diathesis,  13 

arthritic,  244 

Diet  and  disease,  10 
Dilatation  of  heart,  120,  121 
Diphtheria  and  antitoxin,  39 
as  cause  of  epistaxis,  149 

paralysis  in,  v.   infantile  paralysis. 

Diphtheria,  peripheral  neuritis  in,  283 

V.  hospital  sore  throat,  39 

Disease,  abortive,  meaning  of,  31 

and  diet,  10 

and  new  growths,  13 

causes  of,  6 

congenital,  12 

processes  of,  13 

reasons  for  thinking  it  microbic,  29 

Disseminated     sclerosis      v.      peripheral 

neuritis,  296 
Drunk  or  dying,  326 
Dullness  on  percussion,  degrees  of,  67 
Duodenum,  ulcer  of,  156 
Dying  or  drunk,  326 
Dyspepsia  v.  heart  pain,  32 

V.  gastric  ulcer,  182 

Dyspnoea  v.  shortness  of  breath,  58 

Ear,  cough  from,  50 
Eburnation  of  bone,  240 
Effusion,  pleuritic,  102 

pleuritic,  and  pleurisy,  10 1 

Elasticity,  definition  of,  12 
Embolism,  eye  changes  in,  324 

of  mesenteric  artery,  161 

Emphysema,  99 
Empyema,  sweating  in,  48 
Endocardial  v.  exocardial  bruits,  127 
Endocarditis,  pathology  of,  141 
t}T3es  of,  142 


346 


DIFFERENTIAL  DIAGNOSIS 


Endocarditis,  ulcerative,  141 

ulcerative,  diagnosis  of,  144 

ulcerative,  v.  ague,  145 

ulcerative,  v.  tubercle,  145 

ulcerative,  v.  typhoid,  144 

Enuresis,  264 

Environment  and  disease,  10 

Epilepsy,  276 

as  urgency  case,  333 

Jacksonian,  309 

Jacksonian,  v.  idiopathic,  310 

nocturnal  haemorrhage  in,  151 

— —  pupils  in,  333 
Epistaxis,  causes  of,  149 
Erythema  simplex  v.  other  rashes,  43 
Etiology  as  part  of  pathology,  22 
Exanthemata  v.  infantile  paralysis,  292 
Exercise,  influence  of,  on  urine,  186 
Exocardial  v.  endocardial  bruits,  127 
Eyes,  the,  inco-ordination  from,  269 

the,  in  "fits,"  333 

the,    in    anaemia,    purpura,     gout, 

cirrhotic  kidney,   albuminuria,   fevers, 

leucocythaemia,  324 
Eyes,  the,  changes  in  fundi,  in  plumbism, 

refraction    errors,    tubercle,    tumours, 

325 

Face,  the,  in  coma,  338 

the,  in  urgency  cases,  334 

Faeces,  points  in  examination  of,  175 

rectum  full  of,  176 

Fainting  as  urgency  case,  328 
Fat  as  alterer  of  physical  signs,  66 
Fever,  eye  changes  in,  324 

symptoms  of,  35 

Fibroid  phthisis,  origin  of,  91 
Fits,  causes  of,  in  urgency  cases,  333 
Flat  foot,  235 
Fcetor  of  sputum,  55 
Food,  influence  of,  on  urine,  187 
Foot,  flat,  235 
Fremitus,  tactile,  66 

Frequency  of  micturition,    causes  of  in- 
crease in,  188 
Friction  sounds,  pleural,  73 
Frontal  lobes,  function  of,  307 
Froth  at  mouth  in  urgency  cases,  334 
Function  of  cells  in  disease,  14,  15 
Functional  nerve  troubles  v.  sclerosis,  322 
nerve  troubles  v.  organic,  275 

Ganglia,  basal,  of  brain,  308 
Gangrene  of  lung,  fcetor  in,  56 
Gas  in  pleura,  81 
Gastritis  v.  meningitis,  160 


Giddiness  and  uraemia,  216 
Girdle  pain,  288 
Glycosuria,  212 
Gonorrhoeal  rheumatism,  235 
Gout,  233 

changes  in  fundi  oculorum  in,  324 

in  joints,  238 

pathology  of,  210 

peripheral  neuritis  in,  283 

G.  P.  I. ,  tremors  in,  311 
Granulomata,  inflammation  in,  87 
Grating  in  joints,  231 
Growths  as  cause  of  disease,  13,  18 

intrathoracic,  and  pressure,  61 

intrathoracic,    v.    aneurysm,     106, 

107 
Gummata  and  cranial  nerves,  321 
Gums,  haemorrhage  from,  151 

Haematemesis,  causes  of,  154 

V.  haemoptysis,  152 

Haematuria,  203 
Haemic  v.  organic  bruits,  129 
Haemophilia  as  cause  of  epistaxis,  149 
Haemoptysis,  causes  of,  54,  153 

in  chronic  bronchitis,  100 

its  indications,  92 

V.  haematemesis,  152 

Haemorrhage  and  sudden  death,  329 

and  tumours  of  brain,  314 

brain  v.  meninges,  317 

from  mouth,  causes  of,  150 

from  nose,  148 

into  tumours,  272 

in  urgency  cases,  327 

V.  acute  bulbar  paralysis,  321 

Headache  and  uraemia,  216 

in  cerebral  tumours,  323 

Heart  and  pericardium,  diseases  of,  112 

bruits,    exocardial   v.    endocardial, 

127 
Heart  bruits,  importance  of,  116 

bruits,  organic  v.  haemic,  129 

bruits  V.  sounds  of  like  nature,  126 

dilatation  of,  121 

disease,  age  in,  138 

disease  and  epistaxis,  150 

disease  and  sudden  death,  329 

disease,  cough  in,  51 

disease,  general  symptoms  of,  117 

disease,  local  signs  of,  113,  114 

disease,  nervous  v.  muscular,  137 

disease,  pain  in,  61 

disease,  sex  in,  139 

disease,  without  bruits,  135 

enlargement  of,  diagnosis  of,  122 


INDEX 


347 


Heart,  failure  of,  it8 

failure  of,  as  cause  of  disease,  i8 

failure  of,  character  of  sounds  in, 

124 

Heart,  failure  of,  definition  of,   120 

hypertrophy  of,   120 

hypertrophy  of,  diagnosis  of,  122 

hypertrophy  of,  symptoms  of,  121 

its  functions,  117 

■ natural  sounds  of,  115 

organs,  118 

pressure  on,  59 

regularity  of,  115 

■ state  of,  in  hemiplegia,  319 

• valvular  lesions,  effects  of,  125 

• valvular  lesions,  influence  of  indi- 
vidual, 134 

Heat  in  joints,  233 

Hemiansesthesia,  308,  311 

Hemianopsia,  seat  of  lesion  in,  303 

Hemiplegia,  diagnosis  of  seat  of  lesion 
in,  302 

Hemiplegia,  heart  in,  319 

softening  v.  haemorrhage,  318 

temperature  in,  319 

Trousseau  on,  319 

Heredity  and  disease,  12 

in  tubercle,  91 

Hoarseness  of  voice,  74 

Hospital  throat  v.  diphtheria,  39 

Hydatid  hooklets  in  sputum,  55 

H}'perpyrexia,  a  source  of,  48 

Hysteria,  276 

and  laryngeal  troubles,  79,  80 

micturition  in,  264 

V,  disseminated  sclerosis,  297 

Hysterical  joint,  236 

Idiopathic  disease,  10 
Immunity,  meaning  of,  31 
Inadequacy,  renal,  216 
Inco-ordination,  268 

causes  of,  269 

in  peripheral  neuritis,  294 

knee  jerk  in,  311 

Incubation,  meaning  of,  31 

period,  table  of,  33 

Indigestion  and  uraemia,  216 
Indiscriminate  lesions  of  cord,  290 
Infection,  date  of,  31 

V.  contagion,  24 

Inflammation  as  process  of  disease,  14 

in  the  lung,  85 

in  nervous  system,  270 

■ nature  of  irritant  in,  87 

phases  of,  86 


Inflammation,  reparative  side  of,  16 
Influenza,  diagnosis  of,  44 

V.  scarlet  fever,  45 

Inhibition  and  interference,  267 
Inspection  of  chest,  65 
Interference  and  inhibition,  267 
Intestine,  ulcers  of,  as  cause  of  haemor- 
rhage, 156 
Intrathoracic  tumours,  105 
Irregularity  of  heart,  124 
Irritant,    nature   of,    as    influencing    in- 
flammation, 87 
Irritation  of  nerves,  stages  in,  315 
Irritative  lesions  v.  destructive,  315 

Jaundice  and  artificial  light,  167 
Joint,  Charcot's,  240 

gout  in,  238 

grating  in,  231 

heat  in,  233 

hysterical,  236 

pain  in,  230 

osteoarthritis    v.    rheumatic    gout, 

239 
Joint,  redness  in,  233 

rheumatism  in,  238 

stiffness  in,  230 

swelling  of,    231 

traumatism  of,  236 

tubercle  of,  232,  237 

uric  acid  in,  240 

Joints,  affections  of,  229 

affections  of,  family  history  in,  234 

affections   of,    personal  history  in, 

234 

Joints,  affections  of,  differential  diagnosis 

of,  241,  243 
Joints,  affections  of,  eburnation  in,  240 
affections  of,  weather  influence  on, 

243 

Keloid,  explanation  of,  86 

Kidney,  cirrhotic,  eye  changes  in,  324 

cirrhotic,  patholog}^  of,  23 

conditions        causing       secondary 

changes  in,  222 

Kidney  disease  and  epistaxis,  150 

disease,  forms  of,  218 

Kidney,  stone  in,  v.  tubercle  or  carci- 
noma, 224 

Kidney,  surgical,  197 

tubercle  of,  226 

Kidneys,  casts  from,  206 

effect  of  heart  failure  on,  119 

haemorrhage  from,  205 

latent  disease  of,  223 


348 


DIFFERENTIAL  DIAGNOSIS 


Kidneys,  malignant  disease  of,  227 

■  pus  from,  202 

Knee  jerk,  279 

as  test  of  locality  of  inco-ordina- 

tion,  311 
Knee  jerk  in  hysteria,  261 

modifications  of,  260 

occasionally  absent  in  health,  261 

Lactation,  prolonged,  and  salicylates,  241 
Laryngeal  paralysis,  76 

trouble,  blood-spitting  in,  54 

recurrent,  pressure  on,  60 

Laryngitis,  cough  in,  50 
Larynx  in  hysteria,  79 

necessity  of  laryngoscope,  74 

symptoms  of  disease  of,  74 

tumours  of,  51 

ulcers  of,  75 

Lead  poisoning,  eye  changes  in,  325 

peripheral  neuritis  in,  283 

Lesions,  indiscriminate,  of  cord,  290 

irritative  v.  destructive,  290 

Leucocythaemia,  eye  changes  in,  324 

epistaxis  in,  149 

Levels  in  the  nervous  system,  257 
Limbs,  effects  of  heart  failure  on,  119 
Liver,  cirrhosis  of,  180 

cirrhosis  as  cause  of  epistaxis,  150 

diagnosis  of  pain  from,  171 

effects  of  heart  failure  on,  119 

painful  affections  of,  162 

Lumbago  v.  poliomyelitis,  293 
Lunacy  in  urgency  cases,  336 
Lung,  abscess,  foetor  of,  56 

cavity  in,  signs  of,  84 

changes  in,  in  pleural  effusion,  105 

collapse  of,  99 

consumption  of,  200 

disease  and  haemoptysis,  153 

effects  of  heart  failure  on,  118 

gangrene  of,  foetor  of,  56 

inflammation  in,  85,  88 

malignant  disease  of,  55 

tissue,  in  sputum,  55 

Lymphatics,  pressure  on,  in  chest,  59 

Manias,  meaning  of,  276 
Measles,  spots  in  mouth  in,  41 

V.  rotheln,  40 

Medulla,  affections  of,  298 

anatomy  of,  301 

physiology  of,  301 

Melaena,  causes  of,  156 
Meninges,  tumour  of,  291 
Meningitis  and  cranial  nerves,  321 


Meningitis,  of  cord,  290 

V.  gastritis,  160 

V.  myelitis,  316 

V.  pneumonia,  96 

poliomyelitis,  293 

Menstruation,   vicarious,    and   epistaxis, 

150 

Menstruation,    vicarious,    and    hasmate- 

mesis,  154 
Mental  changes,  functional  77.  organic,  278 

in  brain  dfsease,  312 

Mercurialism,  tremors  of,  311 
Mesentery,  embolus  of  artery  in,  i6i 
Microbes  and  disease,  27 

classification  of,  26 

in  sputum,  55 

proofs  of  specificity  of,  26 

reasons  for  suspecting,  29 

rules  governing,  25 

Micturition,  increased  frequency  of,  188 

pathological  variations  of,  263 

reflex,  264 

V.  defsecation,  265 

Mind,  influence  of,  on  urination,  187 

seat  of,  307 

Monarthritis,  234 

Morbus  cordis,  haemoptysis  in,  54 

pain  in,  61 

prognosis  in,  145 

Motions,  examination  of,  175 
Mouth,  froth  at,  334 

haemorrhage  from,  151 

Movements,    central    representation    of, 

257 
Movements,  course  of  nerve  impulses  in, 

256 
Movements,  inco-ordination  of,  268 
Mucus  in  sputum,  53 

in  urine,  192 

Murmurs,  and  sounds  mistaken  for  them, 

126 
Muscles  not  represented  centrally,  257 

reaction  of,  degeneration  in,  269 

symmetrically  used,  311 

Myelitis,  acute,  291 
micturition  in,  264 

Neoplasms,  how  they  kill,  18 

and  septicaemia,  20 

physiology  of,  19 

and  disease,  18 

Nephritis,  dangers  of,  219 

forms  of,  218 

Nephrolithiasis,  225 

pathology  of,  209 

Nerve  cells,  primary  affections  of,  320 


INDEX 


349 


Nerve  diseases,  central  v.  peripheral,  279 
diseases,    differential   diagnosis  of. 


272 

—  diseases, 
toms,  267 


direct   v.    indirect    symp- 


Nerve  diseases,  organic  v.  functional,  275 

diseases,  primary  v.  reflex,  273 

impulses,  motor,  course  of,  256 

Nerves,  cranial,  303,  304,  305 

cranial,  like  motor  spinal,  320 

cranial,  lesions  of,  303 

cranial,  peripheral  v.  central  lesions, 

321 

Nerves,  irritation  of,  stages  in,  315 

peripheral,  functions  of,  253 

thoracic,  pressure  on,  60 

Nervous  system,  anatomy  of,  247 

and  \irgency  cases,  331 

causes  of  disease  in,  270 

diseases  of,  247 

functions  of,  252 

levels  in,  257 

onset  of  diseases  in,  272 

physiology  of,  247 

Neuralgia,  276 

V.  neuritis,  284 

Netir asthenia,  276 

Neuritis,    diphtheritic,    v.    infantile    par- 
alysis, 295 

Neuritis,  inco-ordination  in,  269 

in  occupation  neuroses,  314 

optic,  324 

optic,  and  vision,  324 

peripheral,  281 

peripheral,  forms  of,  282 

peripheral,   v.    amyotrophic   lateral 

sclerosis,  296 

Neuritis,     peripheral,     v.     ataxic     para- 
plegia, 295 

Neuritis,     peripheral,     v.     disseminated 
sclerosis,  296 

Neuritis,   peripheral,  v.   lateral  sclerosis, 
296 

Neuritis,  peripheral,  v.  neuralgia,  284 

Neuritis,  peripheral,  v.  progressive  mus- 
cular atrophy,  293 

Neuritis,    peripheral,   v.    system    lesions 

of  cord,  292 
Neuritis,    peripheral,    v.    tabes    dorsalis, 

294 
Neuron,  the,  247 

the,  functions  of,  252 

Neuroses,  occupation,  312 
Night,  cough  worse  in,  52 

sweating  in  abscess  of  liver,  171 

Nomenclature  of  chest  sounds,  74 


Nose,  bleeding  from,  causes  of,  149 
Nummulation  of  sputum,  54 
Nystagmus,  297 

Obstruction  of  bowels,  172 
Occipital  lobes,  function  of,  307 
Occupation  neuroses,  276,  312 
Oculo-motor  nerves,  304 
CEdema  of  chest,  66,  108 
CEsophagus,  pressure  on,  59 
Olfactory  nerves,  lesions  of,  303 
Operation  in  uraemia,  216 
Optic  nerves,  lesions  of,  303 

neuritis,  324 

Organic  v.  functional  nerve  lesions,  275 
Osier,  Dr. ,  on  bronchopneumonia,  98 
Osteoarthritis,  239 

lipping  of  bone  in,  232 

Oxalates  in  urine,  208 

Pain,  from  old  adhesions,  63 

gastric  v.  cardiac,  62 

girdle,  288 

in  abdomen,  vide  Colic 

in  bone,  features  of,  60 

in  chest,  61 

in  gastric  ulcer,  182 

in  heart  disease,  113 

in  joints,  230 

Palpation  of  chest,  66 
Palpitation  in  heart  disease,  114 
Pancreas,  painful  affections  of,  162 
Paradoxical  anaesthesia,  282 
Paralysis,  acute  bulbar,  321 

after  Jacksonian  epilepsy,  310 

agitans,  310 

infantile,  discussion  of,  292 

infantile,  v.  diphtheria,  295 

infantile,  v.  exanthemata,  294 

in  urgency  cases,  340 

laryngeal,  76 

organic  v.  functional,  277 

peripheral,  v.  central  causes  of,  321 

Paraplegia,  ataxic,  v.  peripheral  neuritis, 

295 
Paraplegia  in  meningitis,  316 
Parasites  and  p}Texia,  9 

as  causes  of  disease,  8 

Parturition,   disturbances    of  micturition 

in,  263 
Pathogenic    microbes,    classification    of, 

28 
Pathology,  definition  of,  i,  22 
Peduncles  of  brain,  affections  of,  298 
Percussion  of  chest,  67 
Pericardio-pleural  friction,  73 


3S^ 


DIFFERENTIAL  DIAGNOSIS 


Pericarditis,  and  uraemia,  216 

pain  in,  61 

Pericardium,  diseases  of,  112 
Perihepatitis,  180 
Peritoneum,  cancer  of,  180 

tubercle  of,  180 

Peritonitis  and  uraemia,  216 
Phagocytosis,  definition  of,  29 
Phosphates,  triple,  meaning  of,  209 
Phosphatic  diabetes,  227 
Phosphorus,  forms  of,  in  urine,  208 
Phthisis,  84 

ad  hcB7noptoe,  90 

after  pneumonia,  94 

and  chronic  bronchitis,  94 

blood-spitting  in,  54 

catarrhal,  89 

■ cough  in,  51 

definition  of,  85 

diarrhoea  in,  94,  177 

fibroid,  89 

fibroid  and  keloid,  89 

from  cold  and  cough,  92 

hsemorrhagic,  89 

pneumonic,  88 

scrofulous,  88 

tuberculo-pneumonic,  88 


Physical  signs,  definition  of,  21 

give  physical  conditions  only,  65 

of  thoracic  disease,  64 

Piles,  176 

"  Pins  and  needles,"  282 

Pleura,  air  or  gas  in,  81 

air  or  gas  in,  origin  of,  80 

effect  of  heart  failure  on,  119 

effusion  into,  causes  of,  102 

effusion  into,  nature  of,  103 

effusion  into,  symptoms  of,  102 

Pleurisy,  acute,  causes  of,  loi 

acute,  pain  in,  61 

• ■  acute,  symptoms  of,  loi 

and  pleural  effusion,  loi 

and  tubercle,  loi 

and  uraemia,  216 

in  chronic  bronchitis,  100 

V.  empyema,  pyrexia  in,  48 

Pleuro-pericardial  friction,  73 
Plumbism,  eye  changes  in,  325 
Pneumonia  and  phthisis,  94 

and  uraemia,  216 

— central,  96 

cough  in,  50 

— ■■ —  diagnosis  of,  95 

haemoptysis  in,  54 

is  it  a  specific  disease?  96 

— — —  V.  intracranial  inflammation,  96 


Pneumothorax,  80 

physical  signs  of,  82 

postulates  for,  8i 

sequelae  of,  83 

shortness  of  breath  in,  82 

symptoms  of,  81 

Poisoning,  pupils  in,  333 

Poisons  as  cause  of  disease,  9 

PoliomyeUtis,  diagnosis  of,  292 

Polyarthritis,  234 

Polypi,  rectal,  176 

Pons,  affections  of,  298 

Portal  fissure,  obstruction  in,  180 

Posterior  longitudinal  bundle,  300,  304 

Pregnancy  and  epistaxis,  150 

and  heart  disease,  147 

Pressure,  intrathoracic,  59,  60 

Processes  of  disease,  general,  13 

Prognosis  in  heart  disease,  145 

Progressive  muscular  atrophy,  293 

Prostate,  enlarged,  micturition  in,  264 

Pseudo-paralysis,  274 

Ptomaine  poisoning  v.  cholera,  43 

Puberty  and  epistaxis,  149 

Pulse,  frequency  of,  in  morbus  cordis,  124 

respiration  ratio  in  pyrexia,  35 

the,  in  urgency  cases,  335,  340 

Pupils,  the,  in  alcoholism,  340 

the,  in  epilepsy,  333 

the,  in  fits,  333 

the,  phases  of,  339,  340 

the,  in  urgency  cases,  338 

the,  stupor  v.  coma,  339 

Purpura  and  epistaxis,  149 

eye  changes  in,  324 

Pus  from  bladder,  202 

in  nephrolithiasis,  224 

in  sputum,  53 

in  urine,  200 

Pyrexia  and  parasites,  9 

in  old  thoracic  disease,  49 

in  phthisis,  94 

in  pleurisy  v.  empyema,  48 

in  thoracic  diseases,  47 

pulse-respiration,  ratio  in,  35 

quickens  respiration,  57 

symptoms  of,  35 

Pyuria,  200 

causes  of,  201 

Rales,  definition  of,  71 
Rashes  of  zymotics,  table  of,  37 
Reaction  of  degeneration,  269 
Rectum,  ballooning  of,  176 

diseases  of,  176 

haemorrhage  from,  157 


INDEX 


351 


Rectum  v.  bladder,  265 
Redness  of  joints,  233 
Reflexes,  paths  of,  259 

• superficial  v.  deep,  259 

varieties  of,  253 

vasomotor,  265 

Refraction,  eye  changes  in,  325 
Renal  inadequacy,  216 
Repair,  limits  of,  in  nerve  tissues,  276 
Resiliency  of  chest  wall,  68 
Respiration,  accelerated,  56 

accelerated,  in  anaemia,  57 

accelerated,  in  chronic  disease,  57 

accelerated,  in  heart  disease,  57 

cogwheel,  72 

in  coma,  340 

in  lar}'ngeal  paralysis,  jj 

ratio  to  pulse  in  pyrexia,  35 

rhythm,  alterations  in,  49 

Retention  of  urine,  causes  of,  217 

V.  suppression,  216 

Rheumatic  gout,  238 

Rheumatism,  cases  where  salicylates  are 

no  use,  241 
Rheumatism,  gonorrhoeal,  235 

joints  in,  238 

peripheral  neuritis  in,  283 

simple  V.  gonorrhoeal,  236 

V.  rheumatoid  arthritis,  242 

Rheumatoid  arthritis,  239 

V.  rheumatism,  242 

Rhonchus,  definition  of,  71 

Rigors  V.  convulsions,  95 

Root  s}TTiptoms,  288 

Rotheln  v.  measles  and  scarlet  fever,  40 

Salicylates,  occasionally  no  use  in  rheu- 
matism, 241 

Salt  as  detector  of  gastric  ulcer,  183 

Scar  tissue,  functions  of,  16 

Scarlet  fever  v.  influenza,  45 

V.  measles,  40 

V.  rotheln,  40 

Scarring  in  varicella,  38 

Schott  treatment  of  morbus  cordis,  146 

Sciatica  from  pressure,  274 

V.  neuritis,  284 

V.  poliomyelitis,  293 

Sclerosis,  amyotrophic,  v.  peripheral 
neuritis,  296 

Sclerosis,  disseminated,  v.  functional 
trouble,  297 

Sclerosis,  disseminated,  v.  peripheral 
neuritis,  296 

Sclerosis,  early  stages  of,  v.  functional 
trouble,  322 


Sclerosis,  lateral,  v.   peripheral  neuritis, 

296 
Sclerosis,  primary,  of  nerve  cells,  320 

secondary,  320 

Segregation,  necessity  for,  33 
Sensation,  cortical  seat  of,  307 

pathways  of,  257 

Septicaemia,  28 

from  neoplasms,  20 

Serum-therapy,  arguments  for,  5 
Shock  and  alcoholism,  329 

nature  of,  313 

Shortness  of  breath  v.  dyspnoea,  58 

Sight,  cortical  seat  of,  307 

Signs,  physical,  of  thoracic  disease,  64 

physical,  v.  symptoms,  21 

Sixth   cranial   nerve,    localisation   from, 

302,  304 
Smell,  cortical  representation  of,  307 
Sodium  phosphate  in  urine,  208 
Spasm,  organic  v.  functional,  277 
Speech  in  laryngeal  paralysis,  77 

anatomy  of,  249 

Spinal  cord,  functions  of,  255 

diseases  of,  285 

Spleen,  heart,  119 

painful  affections  of,  162 

Sputum,  the,  as  aid  to  diagnosis,  52 

blood  in,  54 

foetid,  V.  foul  breath,  56 

foetor  of,  55 

in  pneumonia,  96 

nummulation  of,  54 

qualitative  changes  in,  53 

quantity  of,  53 

Squint,  inco-ordination  in,  269 
Stiffness  of  joints,  230 
Stomach,  effects  of  heart  failure  on,  119 
Stone  in  kidney,  202,  225 

V.  carcinoma,  224 

V.  tubercle,  224 

Strangury,  micturition  in,  265 

definition  of,  204 

Structure  in  disease,  14 

Succussion,  73 

Sugar  in  urine,  212 

Suppression  v.  retention  of  mine,  216 

causes  of,  217 

Supramarginal  lobes,  functions  of,  307 
Surgical  kidney,  197 
Sweat,  the,  in  urgency  cases,  334 
Sweating  at  night,  171 

in  empyema,  48 

Swelling  in  joints,  231 
S}Tnptomatology,  definition  of,  22 
Symptoms,  definition  ol,  21 


352 


DIFFERENTIAL  DIAGNOSIS 


Symptoms,  direct  v.  indirect,   in  nerve, 

267 
Symptoms,  root,  288 

V.  physical  signs,  21 

Synovitis,  237 
Syphilis  of  cord,  290 

V.  septic  venereal  trouble,  46 

V.  variola,  38 

Systems  in  spinal  cord,  287 

lesions  of,   v.    peripheral   neuritis, 

292 

Tabes  dorsalis,  micturition  in,  263,  265 

V.  peripheral  neuritis,  294 

Tactile  vocal  fremitus,  66 
Tegmentum  crura  cerebri,  308 
Temperature  in  bronchitis,  98 

in  bronchopneumonia,  98 

in  capillary  bronchitis,  48 

in  coma,  341 

in  hemiplegia,  319 

in  urgency  cases,  337 

Thalamus,  optic,  308 
Thorax,  pressure  effects  in,  59 

symptoms  of  disease  in,  47 

tumours  of,  105 

Throat,  hospital,  v.  diphtheria,  39 
Tinkling  sounds,  72 
Tissue  debility  as  cause  of  disease,  12 
Tongue,  the,  functions  of,  305 
Toxaemia,  functions  of  body  cells  in,  16 

nervous  phenomena  in,  276 

Tracheal  affections,  blood-spitting  in,  54 

tugging,  109 

Tracts  in  cord,  functions  of,  288,  289 

motor,  256 

sensory,  257 

Traumatism  and  degeneration,  313 

and  tumours,  313 

as  cause  of  disease,  8 

as  urgency  case,  328 

of  joints,  236 

of  nervous  system,  290,  312 

Tremors,  functional  v.  organic,  297 
Triple  phosphates,  meaning  of,  209 
Trophic  influences  of  nerves,  254,  266 
Trousseau  on  hemiplegia,  319 
Tubercle  and  age,  238 

and  bronchopneumonia,  100 

and  pleurisy,  loi 

and   tubercular  v.  nodule  and  no- 
dular, 90 
Tubercle,  cough  in,  50 

heredity  in,  91 

in  choroid,  325 

in  joints,  237 


Tubercle  in  kidney,  202,  226 

in  kidney   v.   stone   or  carcinoma, 

224 
Tubercle,  miliary,  90 

pulmonary,  diagnosis  of,  90 

V.  bronchitis,  91 

V,  bronchopneumonia,  91 

V.  ulcerative  endocarditis,  145 

Tugging,  tracheal,  109 
Tumour  bulging  from  chest,  66 

of  thorax,  105 

of  brain  and  cord,  322 

and  cranial  nerves,  321 

eye  changes  in,  325 

haemorrhage  into,  315 

headache  in,  323 

vomiting  in,  323 

Typhoid,  eye  changes  in,  324 

state,  the,  42 

V.  typhus,  41 

V.  ulcerative  endocarditis,  144 

Ulcer,   duodenal,   as  cause  of  melaena, 

156 
Ulcer,  gastric,  and  hsematemesis,  155 

gastric,  salt  as  detector  of,  183'' 

gastric,  v.  dyspepsia,  182 

of  larynx,  75 

of  nose  as  cause  of  epistaxis,  149 

Ulcerative  endocarditis,  141 
Unconsciousness  in  urgency  cases,  337 
Uraemia,  214 

as  cause  of  vomiting,  159 

as  urgency  case,  333 

diagnosis  of,  215 

pupils  in,  334 

V.   haemorrhage  as  cause  of  coma, 

341 
Urates  in  urine,  192,  207 
Urea  and  uric  acid,  210 
Ureter,  blocking  of,  by  tubercle,  226 

blocking  of,  by  stone,  225 

Urgency  cases,  326 

diagnosis  of,  332 

Uric  acid,  209 

in  joints,  240 

Urinary  organs,  diseases  of,  185 
Urine,  the,  acidity  of,  186 

• blood  in,  203 

bile  in,  190 

casts  in,  205 

characters  of  healthy,  185 

coloior  of,  189 

deposit  in,  192,  194 

incontinence  of,  264 

in  disease,  188 


INDEX 


353 


Urine,  in  urgency  cases,  340 

in  Bright's  disease,  221 

oxalates  in,  208 

pathology  of,  190 

phosphates  in,  208 

pus  in,  200 

quantity  of,  188,  189 

specific  gravity  of,  190 

sugar  in,  212 

suppression  of,  216 

urates  in,  207 

variations  in  health,  i85 

Uvula,  elongated,  causing  cough,  50 

Varicella,  scarring  in,  38 

V.  variola,  38 

Variola  v.  poliomyelitis,  292 

V.  syphilis,  38 

V.  varicella,  38 

Vasomotor  reflexes,  254,  265 
Veins,  enlarged,  on  chest,  66 

pressure  on,  in  thorax,  59 

Venereal  infection,  differential  diagnosis 
oi,  45 


Venereal  infection,    septic  v.    syphilitic, 

46 
Vessels,  lesions  of,  in  urgency  cases,  328 
Vision,  and  optic  neuritis,  324 
as  cause  of  inco-ordination,  269 

double,  304 

Voice,  hoarseness  of,  74 

sounds,  71 

Vomica,  signs  of,  84 
Vomiting,  158 

causes  of,  159 

in  cerebral  tumours,  323 

in  colic,  165 

nervous,  159 

Watson,  Sir  T. ,  on  haemoptysis,  93 
Wear  and  tear  as  causes  of  disease,  ix 
Weather,  the,  and  joint  trouble,  243 
the,  influence  of,  on  urine,  187 

Zymotics  as  cause  of  vomiting,  1 59 

diagnosis  of,  30 

rashes  in,  37 


THE    END 


DEFECTIVE  EYESIGHT: 

The  Principles  of  Its  Relief  by  Glasses. 


BY 


D.  B.  ST.  JOHN  ROOSA,  M.D.,  LL.D., 

Professor  Emeritus  of  Diseases  of  the  Eye  and  Ear;   Post-Graduate  Medical 

School  and  Hospital;   Surgeon  to  the  Manhattan  Eye  and  Ear  Hospital, 

etc.,  etc.  ;  author  of  "A  Clinical  Manual  of  Diseases  of  the  Eye  "  ; 

"Ophthalmic  and  Otic  Memoranda  ";    "A   Practical  Treatise 

on  the  Diseases  of  the  Ear";  "The  Old  Hospital  and  Other 

Papers";  "A  Vest-Pocket  Medical  Lexicon." 

Cloth.    i6mo.    $i.oo,  net. 


Dr.  St.  John  Roosa  has  revised  and  very  carefully  enlarged  the  first  edi- 
tion of  this  work,  which  was  published  under  the  title,  "The  Determination 
of  the  Necessity  for  Wearing  Glasses,"  so  as  to  make  it  a  complete  manual 
for  the  student  and  practitioner.  The  treatise  takes  up  all  conditions  re- 
quiring the  use  of  glasses,  and  indicates  in  the  most  careful  manner  the 
indications  and  rules  for  describing  them.  It  contains  six  chapters,  and 
is  illustrated,  so  that  a  perfect  understanding  of  the  text  is  made  easy.  It  is 
well  known  that  the  author  is  aconservative  in  regard  to  the  value  of  glasses, 
believing  that  there  is  a  limitation  to  their  use,  and  that  they  ought  not  to 
be  prescribed  unless  of  positive  value.  The  revolution  which  has  been  pro- 
duced in  modern  ophthalmic  practice  by  the  invention  of  a  practical  and 
exact  instrument  for  measuring  the  radius  of  the  cornea,  is  fully  dwelt  upon. 
No  pains  have  been  spared  to  make  the  manual  a  complete  guide  to  the 
practitioner  who  wishes  to  understand  and  practise  the  rules  for  the  pre- 
scription of  lenses  for  the  improvement  of  impaired  sight.  The  book  may 
also  be  interesting  to  educated  men  in  all  departments  of  life,  who  desire  to 
be  informed  as  to  advances  that  have  been  made  in  this  interesting  subject, 
one  which  concerns  such  a  large  proportion  of  the  human  race. 


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A  Brief  but  Comprehensive  Text-  A  Handy  Book  of  Reference  for 

Book  for  the  Student.  the  Skilled  Physician. 

KLEMPERER'S 
CLINICAL   DIAGNOSIS. 

BY 

DR.   Q.   KLEflPERER, 

Professor  at  the   University   of  Berlin. 

Second  American  from  the  seventh  and  last  German  edition ;  au- 
thorized translation  by  Nathan  E.  Brill,  A.M.,  M.D.,  Adjunct 
Attending  Physician,  Mt.  Sinai  Hospital,  and  Samuel  M. 
Brickner,  A.m.,  M.D.,  Assistant  Gynaecologist,  Mt.  Sinai 
Hospital  Dispensary.     With  6i  Illustrations. 


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"Those  of  us  who  have  heretofore  made  the  acquaintance 
of  Klemperer's  Clinical  Diagnosis  abroad,  will  have  reason 
to  hail  its  appearance  in  Enghsh  with  satisfaction,  and  for 
the  others  we  cordially  recommend  that  they  do  not  fail 
to  become  famiUar  with  it.  .  .  . 

We  feel  sure  that  the  work  will  have  success  here,  and 
there  is  no  reason  why  its  status  with  German  clinicians  should 
not  be  repeated  with  us,  for  well  and  happily  translated  as 
it  is  the  text  can  scarcely  meet  with  less  appreciation  than 
it  has  so  long  enjoyed."  —  N.  V.  Medical  JournaL 


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Smith 
Introduction  to  the  outlines  of  the 
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